KALEIDA HEALTH Return of Organization Exempt From Income Tax OMB No. 1545-0047 Form 990 Under section 501(c), 527, or 4947(a)(1) of the Internal Revenue Code (except private foundations) Do not enter Social Security numbers on this form as it may be made public. Open to Public Department of the Treasury Internal Revenue Service Information about Form 990 and its instructions is at www.irs.gov/form990. Inspection A For the 2015 calendar year, or tax year beginning , 2015, and ending , 20 C Name of organization D Employer identification number B Check if applicable: KALEIDA HEALTH Address change Doing Business As 16-1533232
Name change Number and street (or P.O. box if mail is not delivered to street address) Room/suite E Telephone number
Initial return 726 EXCHANGE STREET 200 (716) 859-8501
Terminated City or town, state or province, country, and ZIP or foreign postal code Amended G Gross receipts $ return BUFFALO, NY 14210 1,313,720,004. Application F Name and address of principal officer: H(a) Is this a group return for Yes No pending JODY LOMEOsubordinates? X 100 HIGH STREET BUFFALO, NY 14203 H(b) Are all subordinates included? Yes No I Tax-exempt status: X 501(c)(3) 501(c) ( ) (insert no.) 4947(a)(1) or 527 If "No," attach a list. (see instructions) J Website: WWW.KALEIDAHEALTH.ORG H(c) Group exemption number K Form of organization:X Corporation Trust Association Other L Year of formation: 1998M State of legal domicile: NY Part I Summary 1 Briefly describe the organization's mission or most significant activities: SEE SCHEDULE O.
2 Check this box if the organization discontinued its operations or disposed of more than 25% of its net assets. 3 Number of voting members of the governing body (Part VI, line 1a) 3 14. 4 Number of independent voting members of the governing body (Part VI, line 1b) 4 12. 5 Total number of individuals employed in calendar year 2015 (Part V, line 2a) 5 9,280. 6 Total number of volunteers (estimate if necessary) 6 1,626. Activities & Governance 7a Total unrelated business revenue from Part VIII, column (C), line 12 7a 5,084,627. b Net unrelated business taxable income from Form 990-T, line 34 7b -1,126,951. Prior Year Current Year 8 Contributions and grants (Part VIII, line 1h) 20,185,652. 21,313,490. COPY FOR 9 Program service revenue (Part VIII, line 2g) 1,109,372,026. 1,161,013,584. PUBLIC INSPECTION 10 Investment income (Part VIII, column (A), lines 3, 4, and 7d) 9,670,915. 7,497,945.
Revenue 11 Other revenue (Part VIII, column (A), lines 5, 6d, 8c, 9c, 10c, and 11e) 20,508,868. 30,359,860. 12 Total revenue - add lines 8 through 11 (must equal Part VIII, column (A), line 12) 1,159,737,461. 1,220,184,879. 13 Grants and similar amounts paid (Part IX, column (A), lines 1-3) 318,865. 191,300. 14 Benefits paid to or for members (Part IX, column (A), line 4) 0. 0. 15 Salaries, other compensation, employee benefits (Part IX, column (A), lines 5-10) 627,065,263. 663,521,603. 16a Professional fundraising fees (Part IX, column (A), line 11e) 0. 0. b Total fundraising expenses (Part IX, column (D), line 25) 0.
Expenses 17 Other expenses (Part IX, column (A), lines 11a-11d, 11f-24e) 505,805,964. 520,408,012. 18 Total expenses. Add lines 13-17 (must equal Part IX, column (A), line 25) 1,133,190,092. 1,184,120,915. 19 Revenue less expenses. Subtract line 18 from line 12 26,547,369. 36,063,964. Beginning of Current Year End of Year 20 Total assets (Part X, line 16) 1,169,457,849. 1,138,382,417. 21 Total liabilities (Part X, line 26) 935,456,911. 948,334,948.
Net Assets or Net assets or fund balances. Subtract line 21 from line 20 Fund Balances 22 234,000,938. 190,047,469. Part II Signature Block Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. Declaration of preparer (other than officer) is based on all information of which preparer has any knowledge. 11/15/2016 Sign Signature of officer Date Here JON SWIATKOWSKI EVP/CFO Type or print name and title Print/Type preparer's name Preparer's signature DateCheck if PTIN Paid TODD P TERESCO 11/14/2016self-employed P00247720 Preparer Firm's name KPMG LLPFirm's EIN 13-5565207 Use Only Firm's address 515 BROADWAY, 4TH FLOOR ALBANY, NY 12207-2974Phone no. 518-427-4600 May the IRS discuss this return with the preparer shown above? (see instructions) X Yes No For Paperwork Reduction Act Notice, see the separate instructions. Form 990 (2015)
JSA 5E1065 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 2 KALEIDA HEALTH 16-1533232 Form 990 (2015) Page 2 Part III Statement of Program Service Accomplishments Check if Schedule O contains a response or note to any line in this Part III X 1 Briefly describe the organization's mission: ATTACHMENT 1
2 Did the organization undertake any significant program services during the year which were not listed on the prior Form 990 or 990-EZ? YesX No If "Yes," describe these new services on Schedule O. 3 Did the organization cease conducting, or make significant changes in how it conducts, any program services? YesX No If "Yes," describe these changes on Schedule O. 4 Describe the organization's program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.
4a (Code: ) (Expenses $1,065,912,515. including grants of $ 191,300. ) (Revenue $ 1,161,601,069. ) SEE ATTACHMENT 1
4b (Code: ) (Expenses $ including grants of $ ) (Revenue $ )
4c (Code: ) (Expenses $ including grants of $ ) (Revenue $ )
4d Other program services (Describe in Schedule O.) (Expenses $ including grants of $ ) (Revenue $ ) 4e Total program service expenses 1,065,912,515. JSA 5E1020 1.000 Form 990 (2015) 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 3 KALEIDA HEALTH 16-1533232 Form 990 (2015) Page 3 Part IV Checklist of Required Schedules Yes No 1 Is the organization described in section 501(c)(3) or 4947(a)(1) (other than a private foundation)? If "Yes," complete Schedule A 1 X 2 Is the organization required to complete Schedule B, Schedule of Contributors (see instructions)? 2 X 3 Did the organization engage in direct or indirect political campaign activities on behalf of or in opposition to candidates for public office? If "Yes," complete Schedule C, Part I 3 X 4 Section 501(c)(3) organizations. Did the organization engage in lobbying activities, or have a section 501(h) election in effect during the tax year? If "Yes," complete Schedule C, Part II 4 X 5 Is the organization a section 501(c)(4), 501(c)(5), or 501(c)(6) organization that receives membership dues, assessments, or similar amounts as defined in Revenue Procedure 98-19? If "Yes," complete Schedule C, Part III 5 X 6 Did the organization maintain any donor advised funds or any similar funds or accounts for which donors have the right to provide advice on the distribution or investment of amounts in such funds or accounts? If "Yes," complete Schedule D, Part I 6 X 7 Did the organization receive or hold a conservation easement, including easements to preserve open space, the environment, historic land areas, or historic structures? If "Yes," complete Schedule D, Part II 7 X 8 Did the organization maintain collections of works of art, historical treasures, or other similar assets? If "Yes," complete Schedule D, Part III 8 X 9 Did the organization report an amount in Part X, line 21, for escrow or custodial account liability, serve as a custodian for amounts not listed in Part X; or provide credit counseling, debt management, credit repair, or debt negotiation services? If "Yes," complete Schedule D, Part IV 9 X 10 Did the organization, directly or through a related organization, hold assets in temporarily restricted endowments, permanent endowments, or quasi-endowments? If "Yes," complete Schedule D, Part V 10 X 11 If the organization’s answer to any of the following questions is "Yes," then complete Schedule D, Parts VI, VII, VIII, IX, or X as applicable. a Did the organization report an amount for land, buildings, and equipment in Part X, line 10? If "Yes," complete Schedule D, Part VI 11a X b Did the organization report an amount for investments-other securities in Part X, line 12 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VII 11b X c Did the organization report an amount for investments-program related in Part X, line 13 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part VIII 11c X d Did the organization report an amount for other assets in Part X, line 15 that is 5% or more of its total assets reported in Part X, line 16? If "Yes," complete Schedule D, Part IX 11d X e Did the organization report an amount for other liabilities in Part X, line 25? If "Yes," complete Schedule D, Part X 11e X f Did the organization’s separate or consolidated financial statements for the tax year include a footnote that addresses the organization's liability for uncertain tax positions under FIN 48 (ASC 740)? If "Yes," complete Schedule D, Part X 11f X 12a Did the organization obtain separate, independent audited financial statements for the tax year? If "Yes," complete Schedule D, Parts XI and XII 12a X b Was the organization included in consolidated, independent audited financial statements for the tax year? If "Yes," and if the organization answered "No" to line 12a, then completing Schedule D, Parts XI and XII is optional 12b X 13 Is the organization a school described in section 170(b)(1)(A)(ii)? If "Yes," complete Schedule E 13 X 14a Did the organization maintain an office, employees, or agents outside of the United States? 14a X b Did the organization have aggregate revenues or expenses of more than $10,000 from grantmaking, fundraising, business, investment, and program service activities outside the United States, or aggregate foreign investments valued at $100,000 or more? If "Yes," complete Schedule F, Parts I and IV 14b X 15 Did the organization report on Part IX, column (A), line 3, more than $5,000 of grants or other assistance to or for any foreign organization? If "Yes," complete Schedule F, Parts II and IV 15 X 16 Did the organization report on Part IX, column (A), line 3, more than $5,000 of aggregate grants or other assistance to or for foreign individuals? If "Yes," complete Schedule F, Parts III and IV 16 X 17 Did the organization report a total of more than $15,000 of expenses for professional fundraising services on Part IX, column (A), lines 6 and 11e? If "Yes," complete Schedule G, Part I (see instructions) 17 X 18 Did the organization report more than $15,000 total of fundraising event gross income and contributions on Part VIII, lines 1c and 8a? If "Yes," complete Schedule G, Part II 18 X 19 Did the organization report more than $15,000 of gross income from gaming activities on Part VIII, line 9a? If "Yes," complete Schedule G, Part III 19 X Form 990 (2015)
JSA 5E1021 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 4 KALEIDA HEALTH 16-1533232 Form 990 (2015) Page 4 Part IV Checklist of Required Schedules (continued) Yes No 20a Did the organization operate one or more hospital facilities? If "Yes," complete Schedule H 20a X b If "Yes" to line 20a, did the organization attach a copy of its audited financial statements to this return? 20b X 21 Did the organization report more than $5,000 of grants or other assistance to any domestic organization or domestic government on Part IX, column (A), line 1? If "Yes," complete Schedule I, Parts I and II 21 X 22 Did the organization report more than $5,000 of grants or other assistance to or for domestic individuals on Part IX, column (A), line 2? If "Yes," complete Schedule I, Parts I and III 22 X 23 Did the organization answer "Yes" to Part VII, Section A, line 3, 4, or 5 about compensation of the organization's current and former officers, directors, trustees, key employees, and highest compensated employees? If "Yes," complete Schedule J 23 X 24a Did the organization have a tax-exempt bond issue with an outstanding principal amount of more than $100,000 as of the last day of the year, that was issued after December 31, 2002? If "Yes," answer lines 24b through 24d and complete Schedule K. If "No," go to line 25a 24a X b Did the organization invest any proceeds of tax-exempt bonds beyond a temporary period exception? 24b c Did the organization maintain an escrow account other than a refunding escrow at any time during the year to defease any tax-exempt bonds? 24c d Did the organization act as an "on behalf of" issuer for bonds outstanding at any time during the year? 24d 25a Section 501(c)(3), 501(c)(4), and 501(c)(29) organizations. Did the organization engage in an excess benefit transaction with a disqualified person during the year? If "Yes," complete Schedule L, Part I 25a X b Is the organization aware that it engaged in an excess benefit transaction with a disqualified person in a prior year, and that the transaction has not been reported on any of the organization's prior Forms 990 or 990-EZ? If "Yes," complete Schedule L, Part I 25b X 26 Did the organization report any amount on Part X, line 5, 6, or 22 for receivables from or payables to any current or former officers, directors, trustees, key employees, highest compensated employees, or disqualified persons? If "Yes," complete Schedule L, Part II 26 X 27 Did the organization provide a grant or other assistance to an officer, director, trustee, key employee, substantial contributor or employee thereof, a grant selection committee member, or to a 35% controlled entity or family member of any of these persons? If "Yes," complete Schedule L, Part III 27 X 28 Was the organization a party to a business transaction with one of the following parties (see Schedule L, Part IV instructions for applicable filing thresholds, conditions, and exceptions): a A current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV 28a X b A family member of a current or former officer, director, trustee, or key employee? If "Yes," complete Schedule L, Part IV 28b X c An entity of which a current or former officer, director, trustee, or key employee (or a family member thereof) was an officer, director, trustee, or direct or indirect owner? If "Yes," complete Schedule L, Part IV 28c X 29 Did the organization receive more than $25,000 in non-cash contributions? If "Yes," complete Schedule M 29 X 30 Did the organization receive contributions of art, historical treasures, or other similar assets, or qualified conservation contributions? If "Yes," complete Schedule M 30 X 31 Did the organization liquidate, terminate, or dissolve and cease operations? If "Yes," complete Schedule N, Part I 31 X 32 Did the organization sell, exchange, dispose of, or transfer more than 25% of its net assets? If "Yes," complete Schedule N, Part II 32 X 33 Did the organization own 100% of an entity disregarded as separate from the organization under Regulations sections 301.7701-2 and 301.7701-3? If "Yes," complete Schedule R, Part I 33 X 34 Was the organization related to any tax-exempt or taxable entity? If "Yes," complete Schedule R, Part II, III, or IV, and Part V, line 1 34 X 35a Did the organization have a controlled entity within the meaning of section 512(b)(13)? 35a X b If "Yes" to line 35a, did the organization receive any payment from or engage in any transaction with a controlled entity within the meaning of section 512(b)(13)? If "Yes," complete Schedule R, Part V, line 2 35b X 36 Section 501(c)(3) organizations. Did the organization make any transfers to an exempt non-charitable related organization? If "Yes," complete Schedule R, Part V, line 2 36 X 37 Did the organization conduct more than 5% of its activities through an entity that is not a related organization and that is treated as a partnership for federal income tax purposes? If "Yes," complete Schedule R, Part VI 37 X 38 Did the organization complete Schedule O and provide explanations in Schedule O for Part VI, lines 11b and 19? Note. All Form 990 filers are required to complete Schedule O. 38 X Form 990 (2015)
JSA
5E1030 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 5 KALEIDA HEALTH 16-1533232 Form 990 (2015) Page 5 Part V Statements Regarding Other IRS Filings and Tax Compliance Check if Schedule O contains a response or note to any line in this Part V Yes No 1a Enter the number reported in Box 3 of Form 1096. Enter -0- if not applicable 1a 499 b Enter the number of Forms W-2G included in line 1a. Enter -0- if not applicable 1b 0. c Did the organization comply with backup withholding rules for reportable payments to vendors and reportable gaming (gambling) winnings to prize winners? 1c X 2a Enter the number of employees reported on Form W-3, Transmittal of Wage and Tax Statements, filed for the calendar year ending with or within the year covered by this return 2a 9,280 b If at least one is reported on line 2a, did the organization file all required federal employment tax returns? 2b X Note. If the sum of lines 1a and 2a is greater than 250, you may be required to e-file (see instructions) 3a Did the organization have unrelated business gross income of $1,000 or more during the year? 3a X b If "Yes," has it filed a Form 990-T for this year? If "No" to line 3b, provide an explanation in Schedule O 3b X 4a At any time during the calendar year, did the organization have an interest in, or a signature or other authority over, a financial account in a foreign country (such as a bank account, securities account, or other financial account)? 4a X b If “Yes,” enter the name of the foreign country: See instructions for filing requirements for FinCEN Form 114, Report of Foreign Bank and Financial Accounts (FBAR). 5a Was the organization a party to a prohibited tax shelter transaction at any time during the tax year? 5a X b Did any taxable party notify the organization that it was or is a party to a prohibited tax shelter transaction? 5b X c If "Yes" to line 5a or 5b, did the organization file Form 8886-T? 5c 6a Does the organization have annual gross receipts that are normally greater than $100,000, and did the organization solicit any contributions that were not tax deductible as charitable contributions? 6a X b If "Yes," did the organization include with every solicitation an express statement that such contributions or gifts were not tax deductible? 6b 7 Organizations that may receive deductible contributions under section 170(c). a Did the organization receive a payment in excess of $75 made partly as a contribution and partly for goods and services provided to the payor? 7a X b If "Yes," did the organization notify the donor of the value of the goods or services provided? 7b c Did the organization sell, exchange, or otherwise dispose of tangible personal property for which it was required to file Form 8282? 7c X d If "Yes," indicate the number of Forms 8282 filed during the year 7d e Did the organization receive any funds, directly or indirectly, to pay premiums on a personal benefit contract? 7e X f Did the organization, during the year, pay premiums, directly or indirectly, on a personal benefit contract? 7f X g If the organization received a contribution of qualified intellectual property, did the organization file Form 8899 as required? 7g h If the organization received a contribution of cars, boats, airplanes, or other vehicles, did the organization file a Form 1098-C? 7h 8 Sponsoring organizations maintaining donor advised funds. Did a donor advised fund maintained by the sponsoring organization have excess business holdings at any time during the year? 8 9 Sponsoring organizations maintaining donor advised funds. a Did the sponsoring organization make any taxable distributions under section 4966? 9a b Did the sponsoring organization make a distribution to a donor, donor advisor, or related person? 9b 10 Section 501(c)(7) organizations. Enter: a Initiation fees and capital contributions included on Part VIII, line 12 10a b Gross receipts, included on Form 990, Part VIII, line 12, for public use of club facilities 10b 11 Section 501(c)(12) organizations. Enter: a Gross income from members or shareholders 11a b Gross income from other sources (Do not net amounts due or paid to other sources against amounts due or received from them.) 11b 12a Section 4947(a)(1) non-exempt charitable trusts. Is the organization filing Form 990 in lieu of Form 1041? 12a b If "Yes," enter the amount of tax-exempt interest received or accrued during the year 12b 13 Section 501(c)(29) qualified nonprofit health insurance issuers. a Is the organization licensed to issue qualified health plans in more than one state? 13a Note. See the instructions for additional information the organization must report on Schedule O. b Enter the amount of reserves the organization is required to maintain by the states in which the organization is licensed to issue qualified health plans 13b c Enter the amount of reserves on hand 13c 14a Did the organization receive any payments for indoor tanning services during the tax year? 14a X b If "Yes," has it filed a Form 720 to report these payments? If "No," provide an explanation in Schedule O 14b JSA 5E1040 1.000 Form 990 (2015) 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 6 Form 990 (2015) KALEIDA HEALTH 16-1533232 Page 6 Part VI Governance, Management, and Disclosure For each "Yes" response to lines 2 through 7b below, and for a "No" response to line 8a, 8b, or 10b below, describe the circumstances, processes, or changes in Schedule O. See instructions. Check if Schedule O contains a response or note to any line in this Part VI X Section A. Governing Body and Management Yes No 1a Enter the number of voting members of the governing body at the end of the tax year 1a 14 If there are material differences in voting rights among members of the governing body, or if the governing body delegated broad authority to an executive committee or similar committee, explain in Schedule O. b Enter the number of voting members included in line 1a, above, who are independent 1b 12 2 Did any officer, director, trustee, or key employee have a family relationship or a business relationship with any other officer, director, trustee, or key employee? 2 X 3 Did the organization delegate control over management duties customarily performed by or under the direct supervision of officers, directors, or trustees, or key employees to a management company or other person? 3 X 4 Did the organization make any significant changes to its governing documents since the prior Form 990 was filed? 4 X 5 Did the organization become aware during the year of a significant diversion of the organization's assets? 5 X 6 Did the organization have members or stockholders? 6 X 7a Did the organization have members, stockholders, or other persons who had the power to elect or appoint one or more members of the governing body? 7a X b Are any governance decisions of the organization reserved to (or subject to approval by) members, stockholders, or persons other than the governing body? 7b X 8 Did the organization contemporaneously document the meetings held or written actions undertaken during the year by the following: a The governing body? 8a X b Each committee with authority to act on behalf of the governing body? 8b X 9 Is there any officer, director, trustee, or key employee listed in Part VII, Section A, who cannot be reached at the organization's mailing address? If "Yes," provide the names and addresses in Schedule O 9 X Section B. Policies (This Section B requests information about policies not required by the Internal Revenue Code.) Yes No 10a Did the organization have local chapters, branches, or affiliates? 10a X b If "Yes," did the organization have written policies and procedures governing the activities of such chapters, affiliates, and branches to ensure their operations are consistent with the organization's exempt purposes? 10b 11a Has the organization provided a complete copy of this Form 990 to all members of its governing body before filing the form? 11a X b Describe in Schedule O the process, if any, used by the organization to review this Form 990. 12a Did the organization have a written conflict of interest policy? If"No,"gotoline13 12a X b Were officers, directors, or trustees, and key employees required to disclose annually interests that could give rise to conflicts? 12b X c Did the organization regularly and consistently monitor and enforce compliance with the policy? If "Yes," describe in Schedule O how this was done 12c X 13 Did the organization have a written whistleblower policy? 13 X 14 Did the organization have a written document retention and destruction policy? 14 X 15 Did the process for determining compensation of the following persons include a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision? a The organization's CEO, Executive Director, or top management official 15a X b Other officers or key employees of the organization 15b X If "Yes" to line 15a or 15b, describe the process in Schedule O (see instructions). 16a Did the organization invest in, contribute assets to, or participate in a joint venture or similar arrangement with a taxable entity during the year? 16a X b If "Yes," did the organization follow a written policy or procedure requiring the organization to evaluate its participation in joint venture arrangements under applicable federal tax law, and take steps to safeguard the organization's exempt status with respect to such arrangements? 16b X Section C. Disclosure 17 List the states with which a copy of this Form 990 is required to be filed NY, 18 Section 6104 requires an organization to make its Forms 1023 (or 1024 if applicable), 990, and 990-T (Section 501(c)(3)s only) available for public inspection. Indicate how you made these available. Check all that apply. XXOwn website Another's website Upon request Other (explain in Schedule O) 19 Describe in Schedule O whether (and if so, how) the organization made its governing documents, conflict of interest policy, and financial statements available to the public during the tax year. 20 State the name, address, and telephone number of the person who possesses the organization's books and records: JONATHAN SWIATKOWSKI 100 HIGH STREET, 11TH FLOOR SOUTH BUFFALO, NY 14203 716-859-8836 JSA Form 990 (2015) 5E1042 1.000
6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 7 Form 990 (2015) KALEIDA HEALTH 16-1533232 Page 7 Part VII Compensation of Officers, Directors, Trustees, Key Employees, Highest Compensated Employees, and Independent Contractors Check if Schedule O contains a response or note to any line in this Part VII Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees 1a Complete this table for all persons required to be listed. Report compensation for the calendar year ending with or within the organization's tax year. List all of the organization's current officers, directors, trustees (whether individuals or organizations), regardless of amount of compensation. Enter -0- in columns (D), (E), and (F) if no compensation was paid. List all of the organization's current key employees, if any. See instructions for definition of "key employee." List the organization's five current highest compensated employees (other than an officer, director, trustee, or key employee) who received reportable compensation (Box 5 of Form W-2 and/or Box 7 of Form 1099-MISC) of more than $100,000 from the organization and any related organizations. List all of the organization's former officers, key employees, and highest compensated employees who received more than $100,000 of reportable compensation from the organization and any related organizations. List all of the organization's former directors or trustees that received, in the capacity as a former director or trustee of the organization, more than $10,000 of reportable compensation from the organization and any related organizations. List persons in the following order: individual trustees or directors; institutional trustees; officers; key employees; highest compensated employees; and former such persons. Check this box if neither the organization nor any related organization compensated any current officer, director, or trustee. (C) (A) (B)Position (D) (E) (F) Name and Title Average (do not check more than one Reportable Reportable Estimated hours per box, unless person is both an compensation compensation from amount of week (list any officer and a director/trustee) from related other
hours for director or trustee Individual trustee Institutional Officer employee Key employee compensated Highest Former the organizations compensation related organization (W-2/1099-MISC) from the organizations (W-2/1099-MISC) organization below dotted and related line) organizations
(1)EVAN EVANS, MD 1.00 DIRECTOR 0. X 55,289. 0. 257. (2)JODY LOMEO 40.00 PRES/CEO EX-OFFICIO W/VOTE 1.00 X X 1,324,753. 0. 489,360. (3)ROBERT J. HALONEN 1.00 DIRECTOR 0. X 0. 0. 0. (4)JOHN R. KOELMEL 1.00 CHAIRMAN 0. X 0. 0. 0. (5)DAVID A. MILLING, MD 1.00 SECRETARY 0. X 0. 0. 0. (6)HERMAN S. MOGAVERO, JR, MD 1.00 DIRECTOR 0. X 0. 0. 0. (7)FRANCISCO VASQUEZ, PHD 1.00 VICE CHAIR 0. X 0. 0. 0. (8)AMY L. CLIFTON 1.00 DIRECTOR 0. X 0. 0. 0. (9)CHRISTOPHER T. GREENE, ESQ 1.00 DIRECTOR 0. X 0. 0. 0. (10)ROBERT M. ZAK 1.00 DIRECTOR 0. X 0. 0. 0. (11)DARREN J. KING 1.00 DIRECTOR 0. X 0. 0. 0. (12)FRANK CURCI 1.00 DIRECTOR 0. X 0. 0. 0. (13)KEVIN GIBBONS, MD 1.00 DIRECTOR 0. X 0. 0. 0. (14)GEORGE MATTHEWS, MD 1.00 DIRECTOR 1.00 X 0. 0. 0.
JSA Form 990 (2015) 5E1041 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 8 KALEIDA HEALTH 16-1533232 Form 990 (2015) Page 8 Part VII Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued) (A) (B) (C) (D) (E) (F) Name and title Average Position Reportable Reportable Estimated hours per (do not check more than one compensation compensation from amount of week (list any box, unless person is both an from related other hours for officer and a director/trustee) compensation
rdirector or trustee Individual trustee Institutional Officer employee Key employee compensated Highest Former the organizations related organization (W-2/1099-MISC) from the organizations (W-2/1099-MISC) organization below dotted and related line) organizations
( 15) NICHOLAS J. AQUINO, MD 1.00 DIRECTOR 0. X 0. 0. 0. ( 16) WILLIAM I. MAGGIO 1.00 DIRECTOR 0. X 0. 0. 0. ( 17) CHRISTOPHER C. ROSS 1.00 TREASURER 0. X 0. 0. 0. ( 18) MARY LOU RUSIN, EDD, RN 1.00 DIRECTOR 0. X 0. 0. 0. ( 19) ALYSON SPAULDING 40.00 GENERAL COUNSEL 0. X 393,763. 0. 165,759. ( 20) DAVID HUGHES, MD 40.00 EVP, CMO 1.00 X 643,825. 0. 201,969. ( 21) TONI BOOKER 40.00 EVP, CHIEF HUMAN RESOURCES OFC 0. X 547,822. 0. 42,759. ( 22) JONATHAN SWIATKOWSKI 40.00 EVP, CFO 1.50 X 571,770. 0. 166,462. ( 23) JAMAL GHANI 40.00 EVP, COO 0. X 672,928. 0. 37,859. ( 24) DONALD BOYD 40.00 SVP BUSINESS DEVELOPMENT 1.50 X 619,810. 0. 37,562. ( 25) CHRISTOPHER LANE 40.00 SVP OPERATIONS MFS, DMH 0. X 455,506. 0. 37,430. 1b Sub-total 1,380,042. 0. 489,617. c Total from continuation sheets to Part VII, Section A 10,078,006. 0. 1,463,180. d Total (add lines 1b and 1c) 11,458,048. 0. 1,952,797. 2 Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization 560 Yes No 3 Did the organization list any former officer, director, or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual 3 X 4 For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual 4 X 5 Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person 5 X Section B. Independent Contractors 1 Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization's tax year.
(A) (B) (C) Name and business address Description of services Compensation ATTACHMENT 2
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization 70 JSA Form (2015) 5E1055 1.000 990 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 9 KALEIDA HEALTH 16-1533232 Form 990 (2015) Page 8 Part VII Section A. Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees (continued) (A) (B) (C) (D) (E) (F) Name and title Average Position Reportable Reportable Estimated hours per (do not check more than one compensation compensation from amount of week (list any box, unless person is both an from related other hours for officer and a director/trustee) compensation
rdirector or trustee Individual trustee Institutional Officer employee Key employee compensated Highest Former the organizations related organization (W-2/1099-MISC) from the organizations (W-2/1099-MISC) organization below dotted and related line) organizations
( 26) CHERYL KLASS 40.00 SVP OPERATIONS BGMC 0. X 631,169. 0. 472,344. ( 27) ALLEGRA JAROS 40.00 SVP OPERATIONS WCHOB 0. X 425,302. 0. 37,396. ( 28) MICHAEL HUGHES 40.00 SVP, PUBLIC AFFAIRS MARKETING 0. X 335,700. 0. 85,202. ( 29) AARON HOFFMAN, MD 40.00 EMPLOYED PHYSICIAN 0. X 938,743. 0. 43,724. ( 30) CHRISTOPHER MALLAVARAPU 40.00 EMPLOYED PHYSICIAN 0. X 919,404. 0. 50,941. ( 31) JOHN BUTSCH 40.00 EMPLOYED PHYSICIAN 0. X 613,395. 0. 45,144. ( 32) CARROLL HARMON 40.00 EMPLOYED PHYSICIAN 0. X 638,019. 0. 8,613. ( 33) KAVEH VALI, MD 40.00 EMPLOYED PHYSICIAN 0. X 561,417. 0. 30,016. ( 34) JAMES KASKIE 0. FORMER CEO EX-OFFICIO W/ VOTE 0. X 1,109,433. 0. 0.
1b Sub-total c Total from continuation sheets to Part VII, Section A d Total (add lines 1b and 1c) 2 Total number of individuals (including but not limited to those listed above) who received more than $100,000 of reportable compensation from the organization 560 Yes No 3 Did the organization list any former officer, director, or trustee, key employee, or highest compensated employee on line 1a? If "Yes," complete Schedule J for such individual 3 X 4 For any individual listed on line 1a, is the sum of reportable compensation and other compensation from the organization and related organizations greater than $150,000? If “Yes,” complete Schedule J for such individual 4 X 5 Did any person listed on line 1a receive or accrue compensation from any unrelated organization or individual for services rendered to the organization? If “Yes,” complete Schedule J for such person 5 X Section B. Independent Contractors 1 Complete this table for your five highest compensated independent contractors that received more than $100,000 of compensation from the organization. Report compensation for the calendar year ending with or within the organization's tax year.
(A) (B) (C) Name and business address Description of services Compensation
2 Total number of independent contractors (including but not limited to those listed above) who received more than $100,000 in compensation from the organization JSA Form (2015) 5E1055 1.000 990 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 10 Form 990 (2015) KALEIDA HEALTH 16-1533232 Page 9 Part VIII Statement of Revenue Check if Schedule O contains a response or note to any line in this Part VIII (A) (B) (C) (D) Total revenue Related or Unrelated Revenue exempt business excluded from tax function revenue under sections revenue 512-514
1a Federated campaigns 1a b Membership dues 1b c Fundraising events 1c d Related organizations 1d 4,810,863. e Government grants (contributions) 1e 13,816,859. f All other contributions, gifts, grants, and similar amounts not included above 1f 2,685,768. g Noncash contributions included in lines 1a-1f: $ 4,354,054. Contributions, Gifts, Grants and Other Similar Amounts hTotal.Add lines 1a-1f 21,313,490. Business Code
2a NET PATIENT SERVICE REVENUE 623990 1,155,262,552. 1,155,262,552. b MANAGEMENT FEES 561000 72,900. 72,900. c LAB SERVICES 621500 5,678,132. 5,678,132. d e f All other program service revenue Program Service Revenue g Total. Add lines 2a-2f 1,161,013,584. 3 Investment income (including dividends, interest, and other similar amounts)ATTACHMENT 3 5,108,876. -234,094. -939,938. 6,282,908. 4 Income from investment of tax-exempt bond proceeds 0. 5 Royalties 0. (i) Real (ii) Personal 6a Gross rents 2,245,546. b Less: rental expenses c Rental income or (loss) 2,245,546. d Net rental income or (loss) 2,245,546. 73,363. 2,172,183. 7a Gross amount from sales of (i) Securities (ii) Other assets other than inventory 95,832,397. 91,797. b Less: cost or other basis and sales expenses 93,501,535. 33,590. c Gain or (loss) 2,330,862. 58,207. d Net gain or (loss) 2,389,069. 2,389,069. 8a Gross income from fundraising events (not including $ of contributions reported on line 1c). See Part IV, line 18 a b Less: direct expenses b
Other Revenue c Net income or (loss) from fundraising events 0. 9a Gross income from gaming activities. SeePartIV,line19 a b Less: direct expenses b c Net income or (loss) from gaming activities 0. 10a Gross sales of inventory, less returns and allowances a b Less: cost of goods sold b c Net income or (loss) from sales of inventory 0. Miscellaneous Revenue Business Code
11a REBATE REVENUE 900099 22,221,457. 22,221,457. b UNIVERSITY LEASE INCOME 531120 1,546,664. 1,546,664. c VENDING MACHINE COMMISSIONS 900099 926,612. 926,612. d All other revenue 541610 3,419,581. 821,579. 200,170. 2,397,832. e Total. Add lines 11a-11d 28,114,314. 12 Total revenue. See instructions. 1,220,184,879. 1,155,850,037. 5,084,627. 37,936,725. JSA Form 990 (2015) 5E1051 1.000
6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 11 Form 990 (2015) KALEIDA HEALTH 16-1533232 Page 10 Part IX Statement of Functional Expenses Section 501(c)(3) and 501(c)(4) organizations must complete all columns. All other organizations must complete column (A). Check if Schedule O contains a response or note to any line in this Part IX Do not include amounts reported on lines 6b, 7b, (A) (B) (C) (D) Total expenses Program service Management and Fundraising 8b, 9b, and 10b of Part VIII. expenses general expenses expenses
1 Grants and other assistance to domestic organizations and domestic governments. See Part IV, line 21 191,300. 191,300. 2 Grants and other assistance to domestic individuals. See Part IV, line 22 0. 3 Grants and other assistance to foreign organizations, foreign governments, and foreign individuals. See Part IV, lines 15 and 16 0. 4 Benefits paid to or for members 0. 5 Compensation of current officers, directors, trustees, and key employees 6,677,637. 6,677,637. 6 Compensation not included above, to disqualified persons (as defined under section 4958(f)(1)) and persons described in section 4958(c)(3)(B) 0. 7 Other salaries and wages 484,399,362. 450,161,052. 34,238,310. 8 Pension plan accruals and contributions (include section 401(k) and 403(b) employer contributions) 38,270,492. 33,831,482. 4,439,010. 9 Other employee benefits 98,725,674. 90,219,108. 8,506,566. 10 Payroll taxes 35,448,438. 33,035,630. 2,412,808. 11 Fees for services (non-employees): a Management 0. b Legal 2,160,577. 1,105,325. 1,055,252. c Accounting 487,597. 53,350. 434,247. d Lobbying 236,012. 236,012. e Professional fundraising services. See Part IV, line 17 0. f Investment management fees 0. g Other. (If line 11g amount exceeds 10% of line 25, column (A) amount, list line 11g expenses on Schedule O.) ATCH 4 122,562,255. 113,555,235. 9,007,020. 12 Advertising and promotion 4,310,212. 3,667,141. 643,071. 13 Office expenses 2,505,348. 2,004,387. 500,961. 14 Information technology 0. 15 Royalties 0. 16 Occupancy 9,996,149. 4,197,042. 5,799,107. 17 Travel 909,625. 701,749. 207,876. 18 Payments of travel or entertainment expenses for any federal, state, or local public officials 0. 19 Conferences, conventions, and meetings 0. 20 Interest 14,514,201. 11,611,361. 2,902,840. 21 Payments to affiliates 0. 22 Depreciation, depletion, and amortization 61,447,048. 47,038,795. 14,408,253. 23 Insurance 14,117,675. 10,127,819. 3,989,856. 24 Other expenses. Itemize expenses not covered above (List miscellaneous expenses in line 24e. If line 24e amount exceeds 10% of line 25, column (A) amount, list line 24e expenses on Schedule O.) aHEALTH CARE SUPPLIES 203,050,459. 202,972,510. 77,949. bEQUIPMENT RENTAL & MAINTENAN 28,628,512. 12,863,420. 15,765,092. cSERVICE CONTRACTS 12,729,468. 10,451,202. 2,278,266. dUTILITIES 7,559,997. 5,968,440. 1,591,557. e All other expenses 35,192,877. 32,156,167. 3,036,710. 25 Total functional expenses. Add lines 1 through 24e 1,184,120,915. 1,065,912,515. 118,208,400. 26 Joint costs. Complete this line only if the organization reported in column (B) joint costs from a combined educational campaign and fundraising solicitation. Check here if following SOP 98-2 (ASC 958-720) 0. JSA Form 990 (2015) 5E1052 1.000
6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 12 KALEIDA HEALTH 16-1533232 Form 990 (2015) Page 11 Part X Balance Sheet Check if Schedule O contains a response or note to any line in this Part X (A) (B) Beginning of year End of year 1 Cash - non-interest-bearing 74,063,634.1 41,396,112. 2 Savings and temporary cash investments 53,471,293.2 44,682,583. 3 Pledges and grants receivable, net 0.3 0. 4 Accounts receivable, net 136,503,002.4 159,866,006. 5 Loans and other receivables from current and former officers, directors, trustees, key employees, and highest compensated employees. Complete Part II of Schedule L 26,982,367.5 0. 6 Loans and other receivables from other disqualified persons (as defined under section 4958(f)(1)), persons described in section 4958(c)(3)(B), and contributing employers and sponsoring organizations of section 501(c)(9) voluntary employees' beneficiary organizations (see instructions). Complete Part II of Schedule L 0.6 0. 7 Notes and loans receivable, net 0.7 0. 8 Inventories for sale or use 22,794,299.8 25,724,911. Assets 9 Prepaid expenses and deferred charges ATCH 5 13,640,606.9 10,908,230. 10a Land, buildings, and equipment: cost or other basis. Complete Part VI of Schedule D 10a 1562963276. b Less: accumulated depreciation 10b 1081030326. 426,127,201.10c 481,932,950. 11 Investments - publicly traded securities ATCH 6 86,642,646.11 74,551,845. 12 Investments - other securities. See Part IV, line 11 71,923,551.12 66,484,188. 13 Investments - program-related. See Part IV, line 11 0.13 0. 14 Intangible assets 0.14 0. 15 Other assets. See Part IV, line 11 257,309,250.15 232,835,592. 16 Total assets. Add lines 1 through 15 (must equal line 34) 1,169,457,849.16 1,138,382,417. 17 Accounts payable and accrued expenses 133,088,661.17 149,661,885. 18 Grants payable 0.18 0. 19 Deferred revenue 0.19 0. 20 Tax-exempt bond liabilities 63,946,133.20 0. 21 Escrow or custodial account liability. Complete Part IV of Schedule D 0.21 0. 22 Loans and other payables to current and former officers, directors, trustees, key employees, highest compensated employees, and disqualified persons. Complete Part II of Schedule L 0.22 0. Liabilities 23 Secured mortgages and notes payable to unrelated third parties ATCH 7 232,383,053.23 313,990,121. 24 Unsecured notes and loans payable to unrelated third parties 0.24 0. 25 Other liabilities (including federal income tax, payables to related third parties, and other liabilities not included on lines 17-24). Complete Part X of Schedule D 506,039,064.25 484,682,942. 26 Total liabilities. Add lines 17 through 25 935,456,911.26 948,334,948. Organizations that follow SFAS 117 (ASC 958), check here X and complete lines 27 through 29, and lines 33 and 34. 27 Unrestricted net assets 96,795,381.27 67,087,683. 28 Temporarily restricted net assets 121,724,799.28 103,226,405. 29 Permanently restricted net assets 15,480,758.29 19,733,381. Organizations that do not follow SFAS 117 (ASC 958), check here and Fund Balances complete lines 30 through 34. 30 Capital stock or trust principal, or current funds 30 31 Paid-in or capital surplus, or land, building, or equipment fund 31 32 Retained earnings, endowment, accumulated income, or other funds 32 33 Total net assets or fund balances Net Assets or 234,000,938.33 190,047,469. 34 Total liabilities and net assets/fund balances 1,169,457,849.34 1,138,382,417. Form 990 (2015)
JSA
5E1053 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 13 KALEIDA HEALTH 16-1533232 Form 990 (2015) Page 12 Part XI Reconciliation of Net Assets Check if Schedule O contains a response or note to any line in this Part XI X 1 Total revenue (must equal Part VIII, column (A), line 12) 1 1,220,184,879. 2 Total expenses (must equal Part IX, column (A), line 25) 2 1,184,120,915. 3 Revenue less expenses. Subtract line 2 from line 1 3 36,063,964. 4 Net assets or fund balances at beginning of year (must equal Part X, line 33, column (A)) 4 234,000,938. 5 Net unrealized gains (losses) on investments 5 -8,888,118. 6 Donated services and use of facilities 6 0. 7 Investment expenses 7 0. 8 Prior period adjustments 8 0. 9 Other changes in net assets or fund balances (explain in Schedule O) 9 -71,129,315. 10 Net assets or fund balances at end of year. Combine lines 3 through 9 (must equal Part X, line 33, column (B)) 10 190,047,469. Part XII Financial Statements and Reporting Check if Schedule O contains a response or note to any line in this Part XII Yes No 1 Accounting method used to prepare the Form 990: CashX Accrual Other If the organization changed its method of accounting from a prior year or checked "Other," explain in Schedule O. 2a Were the organization's financial statements compiled or reviewed by an independent accountant? 2a X If "Yes," check a box below to indicate whether the financial statements for the year were compiled or reviewed on a separate basis, consolidated basis, or both: Separate basis Consolidated basis Both consolidated and separate basis b Were the organization's financial statements audited by an independent accountant? 2b X If "Yes," check a box below to indicate whether the financial statements for the year were audited on a separate basis, consolidated basis, or both: Separate basisX Consolidated basis Both consolidated and separate basis c If "Yes" to line 2a or 2b, does the organization have a committee that assumes responsibility for oversight of the audit, review, or compilation of its financial statements and selection of an independent accountant? 2c X If the organization changed either its oversight process or selection process during the tax year, explain in Schedule O. 3a As a result of a federal award, was the organization required to undergo an audit or audits as set forth in the Single Audit Act and OMB Circular A-133? 3a X b If "Yes," did the organization undergo the required audit or audits? If the organization did not undergo the required audit or audits, explain why in Schedule O and describe any steps taken to undergo such audits. 3b X Form 990 (2015)
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5E1054 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 14 SCHEDULE A Public Charity Status and Public Support OMB No. 1545-0047 (Form 990 or 990-EZ) Complete if the organization is a section 501(c)(3) organization or a section 4947(a)(1) nonexempt charitable trust. Department of the Treasury Attach to Form 990 or Form 990-EZ. Open to Public Internal Revenue Service Information about Schedule A (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990. Inspection Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 Part I Reason for Public Charity Status (All organizations must complete this part.) See instructions. The organization is not a private foundation because it is: (For lines 1 through 11, check only one box.) 1 A church, convention of churches, or association of churches described in section 170(b)(1)(A)(i). 2 A school described in section 170(b)(1)(A)(ii). (Attach Schedule E (Form 990 or 990-EZ).) 3 X A hospital or a cooperative hospital service organization described in section 170(b)(1)(A)(iii). 4 A medical research organization operated in conjunction with a hospital described in section 170(b)(1)(A)(iii). Enter the hospital's name, city, and state: 5 An organization operated for the benefit of a college or university owned or operated by a governmental unit described in section 170(b)(1)(A)(iv). (Complete Part II.) 6 A federal, state, or local government or governmental unit described in section 170(b)(1)(A)(v). 7 An organization that normally receives a substantial part of its support from a governmental unit or from the general public described in section 170(b)(1)(A)(vi). (Complete Part II.) 8 A community trust described in section 170(b)(1)(A)(vi). (Complete Part II.) 9 An organization that normally receives: (1) more than 331/3 % of its support from contributions, membership fees, and gross receipts from activities related to its exempt functions - subject to certain exceptions, and (2) no more than 331/3 %ofits support from gross investment income and unrelated business taxable income (less section 511 tax) from businesses acquired by the organization after June 30, 1975. See section 509(a)(2). (Complete Part III.) 10 An organization organized and operated exclusively to test for public safety. See section 509(a)(4). 11 An organization organized and operated exclusively for the benefit of, to perform the functions of, or to carry out the purposes of one or more publicly supported organizations described in section 509(a)(1) or section 509(a)(2). See section 509(a)(3). Check the box in lines 11a through 11d that describes the type of supporting organization and complete lines 11e, 11f, and 11g. a Type I. A supporting organization operated, supervised, or controlled by its supported organization(s), typically by giving the supported organization(s) the power to regularly appoint or elect a majority of the directors or trustees of the supporting organization. You must complete Part IV, Sections A and B. b Type II. A supporting organization supervised or controlled in connection with its supported organization(s), by having control or management of the supporting organization vested in the same persons that control or manage the supported organization(s). You must complete Part IV, Sections A and C. c Type III functionally integrated. A supporting organization operated in connection with, and functionally integrated with, its supported organization(s) (see instructions). You must complete Part IV, Sections A, D, and E. d Type III non-functionally integrated. A supporting organization operated in connection with its supported organization(s) that is not functionally integrated. The organization generally must satisfy a distribution requirement and an attentiveness requirement (see instructions). You must complete Part IV, Sections A and D, and Part V. e Check this box if the organization received a written determination from the IRS that it is a Type I, Type II, Type III functionally integrated, or Type III non-functionally integrated supporting organization. f Enter the number of supported organizations g Provide the following information about the supported organization(s). (i) Name of supported organization (ii) EIN (iii) Type of organization (iv) Is the organization (v) Amount of monetary (vi) Amount of (described on lines 1-9 listed in your governing support (see other support (see above (see instructions)) document? instructions) instructions)
Yes No
(A)
(B)
(C)
(D)
(E)
Total For Paperwork Reduction Act Notice, see the Instructions for Schedule A (Form 990 or 990-EZ) 2015 Form 990 or 990-EZ. JSA 5E1210 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 15 KALEIDA HEALTH 16-1533232 Schedule A (Form 990 or 990-EZ) 2015 Page 2 Part II Support Schedule for Organizations Described in Sections 170(b)(1)(A)(iv) and 170(b)(1)(A)(vi) (Complete only if you checked the box on line 5, 7, or 8 of Part I or if the organization failed to qualify under Part III. If the organization fails to qualify under the tests listed below, please complete Part III.) Section A. Public Support Calendar year (or fiscal year beginning in) (a) 2011 (b) 2012 (c) 2013 (d) 2014 (e) 2015 (f) Total 1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") 2 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf 3 The value of services or facilities furnished by a governmental unit to the organization without charge 4 Total. Add lines 1 through 3 5 The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f) 6 Public support. Subtract line 5 from line 4. Section B. Total Support Calendar year (or fiscal year beginning in) (a) 2011 (b) 2012 (c) 2013 (d) 2014 (e) 2015 (f) Total 7 Amounts from line 4 8 Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources 9 Net income from unrelated business activities, whether or not the business is regularly carried on 10 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) 11 Total support. Add lines 7 through 10 12 Gross receipts from related activities, etc. (see instructions) 12 13 First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here Section C. Computation of Public Support Percentage 14 Public support percentage for 2015 (line 6, column (f) divided by line 11, column (f)) 14 % 15 Public support percentage from 2014 Schedule A, Part II, line 14 15 % 16a 331/3% support test - 2015. If the organization did not check the box on line 13, and line 14 is 331/3 % or more, check this box and stop here. The organization qualifies as a publicly supported organization b331/3% support test - 2014. If the organization did not check a box on line 13 or 16a, and line 15 is 331/3 %ormore, check this box and stop here. The organization qualifies as a publicly supported organization 17a 10%-facts-and-circumstances test - 2015. If the organization did not check a box on line 13, 16a, or 16b, and line 14 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain in Part VI how the organization meets the "facts-and-circumstances” test. The organization qualifies as a publicly supported organization b 10%-facts-and-circumstances test - 2014. If the organization did not check a box on line 13, 16a, 16b, or 17a, and line 15 is 10% or more, and if the organization meets the "facts-and-circumstances" test, check this box and stop here. Explain in Part VI how the organization meets the "facts-and-circumstances" test. The organization qualifies as a publicly supported organization 18 Private foundation. If the organization did not check a box on line 13, 16a, 16b, 17a, or 17b, check this box and see instructions Schedule A (Form 990 or 990-EZ) 2015
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5E1220 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 16 KALEIDA HEALTH 16-1533232 Schedule A (Form 990 or 990-EZ) 2015 Page 3 Part III Support Schedule for Organizations Described in Section 509(a)(2) (Complete only if you checked the box on line 9 of Part I or if the organization failed to qualify under Part II. If the organization fails to qualify under the tests listed below, please complete Part II.) Section A. Public Support Calendar year (or fiscal year beginning in) (a) 2011 (b) 2012 (c) 2013 (d) 2014 (e) 2015 (f) Total 1 Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") 2 Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose 3 Gross receipts from activities that are not an unrelated trade or business under section 513 4 Tax revenues levied for the organization's benefit and either paid to or expended on its behalf 5 The value of services or facilities furnished by a governmental unit to the organization without charge 6Total.Add lines 1 through 5 7a Amounts included on lines 1, 2, and 3 received from disqualified persons b Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year c Add lines 7a and 7b 8 Public support. (Subtract line 7c from line 6.) Section B. Total Support Calendar year (or fiscal year beginning in) (a) 2011 (b) 2012 (c) 2013 (d) 2014 (e) 2015 (f) Total 9 Amounts from line 6 10a Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources b Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975 c Add lines 10a and 10b 11 Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on 12 Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) 13 Total support. (Add lines 9, 10c, 11, and 12.) 14 First five years. If the Form 990 is for the organization's first, second, third, fourth, or fifth tax year as a section 501(c)(3) organization, check this box and stop here Section C. Computation of Public Support Percentage 15 Public support percentage for 2015 (line 8, column (f) divided by line 13, column (f)) 15 % 16 Public support percentage from 2014 Schedule A, Part III, line 15 16 % Section D. Computation of Investment Income Percentage 17 Investment income percentage for 2015 (line 10c, column (f) divided by line 13, column (f)) 17 % 18 Investment income percentage from 2014 Schedule A, Part III, line 17 18 % 19a 33 1/3% support tests - 2015. If the organization did not check the box on line 14, and line 15 is more than 331/3 %, and line 17 is not more than 331/3 %, check this box and stop here. The organization qualifies as a publicly supported organization b 33 1/3% support tests - 2014. If the organization did not check a box on line 14 or line 19a, and line 16 is more than 331/3 %, and line 18 is not more than 331/3 %, check this box and stop here. The organization qualifies as a publicly supported organization 20 Private foundation. If the organization did not check a box on line 14, 19a, or 19b, check this box and see instructions JSA Schedule A (Form 990 or 990-EZ) 2015 5E1221 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 17 KALEIDA HEALTH 16-1533232 Schedule A (Form 990 or 990-EZ) 2015 Page 4 Part IV Supporting Organizations (Complete only if you checked a box in line 11 of Part I. If you checked 11a of Part I, complete Sections A and B. If you checked 11b of Part I, complete Sections A and C. If you checked 11c of Part I, complete Sections A, D, and E. If you checked 11d of Part I, complete Sections A and D, and complete Part V.) Section A. All Supporting Organizations Yes No 1 Are all of the organization’s supported organizations listed by name in the organization’s governing documents? If "No," describe in Part VI how the supported organizations are designated. If designated by class or purpose, describe the designation. If historic and continuing relationship, explain. 1 2 Did the organization have any supported organization that does not have an IRS determination of status under section 509(a)(1) or (2)? If "Yes," explain in Part VI how the organization determined that the supported organization was described in section 509(a)(1) or (2). 2 3a Did the organization have a supported organization described in section 501(c)(4), (5), or (6)? If "Yes," answer (b) and (c) below. 3a b Did the organization confirm that each supported organization qualified under section 501(c)(4), (5), or (6) and satisfied the public support tests under section 509(a)(2)? If "Yes," describe in Part VI when and how the organization made the determination. 3b c Did the organization ensure that all support to such organizations was used exclusively for section 170(c)(2)(B) purposes? If "Yes," explain in Part VI what controls the organization put in place to ensure such use. 3c 4a Was any supported organization not organized in the United States ("foreign supported organization")? If "Yes," and if you checked 11a or 11b in Part I, answer (b) and (c) below. 4a b Did the organization have ultimate control and discretion in deciding whether to make grants to the foreign supported organization? If "Yes," describe in Part VI how the organization had such control and discretion despite being controlled or supervised by or in connection with its supported organizations. 4b c Did the organization support any foreign supported organization that does not have an IRS determination under sections 501(c)(3) and 509(a)(1) or (2)? If "Yes," explain in Part VI what controls the organization used to ensure that all support to the foreign supported organization was used exclusively for section 170(c)(2)(B) purposes. 4c 5a Did the organization add, substitute, or remove any supported organizations during the tax year? If "Yes," answer (b) and (c) below (if applicable). Also, provide detail in Part VI, including (i) the names and EIN numbers of the supported organizations added, substituted, or removed; (ii) the reasons for each such action; (iii) the authority under the organization's organizing document authorizing such action; and (iv) how the action was accomplished (such as by amendment to the organizing document). 5a b Type I or Type II only. Was any added or substituted supported organization part of a class already designated in the organization's organizing document? 5b c Substitutions only. Was the substitution the result of an event beyond the organization's control? 5c
6 Did the organization provide support (whether in the form of grants or the provision of services or facilities) to anyone other than (i) its supported organizations, (ii) individuals that are part of the charitable class benefited by one or more of its supported organizations, or (iii) other supporting organizations that also support or benefit one or more of the filing organization’s supported organizations? If "Yes," provide detail in Part VI. 6 7 Did the organization provide a grant, loan, compensation, or other similar payment to a substantial contributor (defined in section 4958(c)(3)(C)), a family member of a substantial contributor, or a 35% controlled entity with regard to a substantial contributor? If "Yes," complete Part I of Schedule L (Form 990 or 990-EZ). 7 8 Did the organization make a loan to a disqualified person (as defined in section 4958) not described in line 7? If "Yes," complete Part I of Schedule L (Form 990 or 990-EZ). 8 9a Was the organization controlled directly or indirectly at any time during the tax year by one or more disqualified persons as defined in section 4946 (other than foundation managers and organizations described in section 509(a)(1) or (2))? If "Yes," provide detail in Part VI. 9a b Did one or more disqualified persons (as defined in line 9a) hold a controlling interest in any entity in which the supporting organization had an interest? If "Yes," provide detail in Part VI. 9b c Did a disqualified person (as defined in line 9a) have an ownership interest in, or derive any personal benefit from, assets in which the supporting organization also had an interest? If "Yes," provide detail in Part VI. 9c 10 a Was the organization subject to the excess business holdings rules of section 4943 because of section 4943(f) (regarding certain Type II supporting organizations, and all Type III non-functionally integrated supporting organizations)? If "Yes," answer 10b below. 10a b Did the organization have any excess business holdings in the tax year? (Use Schedule C, Form 4720, to determine whether the organization had excess business holdings.) 10b JSA Schedule A (Form 990 or 990-EZ) 2015
5E1229 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 18 KALEIDA HEALTH 16-1533232 Schedule A (Form 990 or 990-EZ) 2015 Page 5 Part IV Supporting Organizations (continued) Yes No 11 Has the organization accepted a gift or contribution from any of the following persons? a A person who directly or indirectly controls, either alone or together with persons described in (b) and (c) below, the governing body of a supported organization? 11a b A family member of a person described in (a) above? 11b c A 35% controlled entity of a person described in (a) or (b) above? If “Yes” to a, b, or c, provide detail in Part VI. 11c Section B. Type I Supporting Organizations Yes No 1 Did the directors, trustees, or membership of one or more supported organizations have the power to regularly appoint or elect at least a majority of the organization’s directors or trustees at all times during the tax year? If "No," describe in Part VI how the supported organization(s) effectively operated, supervised, or controlled the organization’s activities. If the organization had more than one supported organization, describe how the powers to appoint and/or remove directors or trustees were allocated among the supported organizations and what conditions or restrictions, if any, applied to such powers during the tax year. 1 2 Did the organization operate for the benefit of any supported organization other than the supported organization(s) that operated, supervised, or controlled the supporting organization? If "Yes," explain in Part VI how providing such benefit carried out the purposes of the supported organization(s) that operated, supervised, or controlled the supporting organization. 2 Section C. Type II Supporting Organizations Yes No 1 Were a majority of the organization’s directors or trustees during the tax year also a majority of the directors or trustees of each of the organization’s supported organization(s)? If "No," describe in Part VI how control or management of the supporting organization was vested in the same persons that controlled or managed the supported organization(s). 1 Section D. All Type III Supporting Organizations Yes No 1 Did the organization provide to each of its supported organizations, by the last day of the fifth month of the organization’s tax year, (i) a written notice describing the type and amount of support provided during the prior tax year, (ii) a copy of the Form 990 that was most recently filed as of the date of notification, and (iii) copies of the organization’s governing documents in effect on the date of notification, to the extent not previously provided? 1 2 Were any of the organization’s officers, directors, or trustees either (i) appointed or elected by the supported organization(s) or (ii) serving on the governing body of a supported organization? If "No," explain in Part VI how the organization maintained a close and continuous working relationship with the supported organization(s). 2 3 By reason of the relationship described in (2), did the organization’s supported organizations have a significant voice in the organization’s investment policies and in directing the use of the organization’s income or assets at all times during the tax year? If "Yes," describe in Part VI the role the organization’s supported organizations played in this regard. 3 Section E. Type III Functionally-Integrated Supporting Organizations 1 Check the box next to the method that the organization used to satisfy the Integral Part Test during the year (see instructions): a The organization satisfied the Activities Test. Complete line 2 below. b The organization is the parent of each of its supported organizations. Complete line 3 below. c The organization supported a governmental entity. Describe in Part VI how you supported a government entity (see instructions). Yes No 2 Activities Test. Answer (a) and (b) below. a Did substantially all of the organization’s activities during the tax year directly further the exempt purposes of the supported organization(s) to which the organization was responsive? If "Yes," then in Part VI identify those supported organizations and explain how these activities directly furthered their exempt purposes, how the organization was responsive to those supported organizations, and how the organization determined that these activities constituted substantially all of its activities. 2a b Did the activities described in (a) constitute activities that, but for the organization’s involvement, one or more of the organization’s supported organization(s) would have been engaged in? If "Yes," explain in Part VI the reasons for the organization’s position that its supported organization(s) would have engaged in these activities but for the organization’s involvement. 2b 3 Parent of Supported Organizations. Answer (a) and (b) below. a Did the organization have the power to regularly appoint or elect a majority of the officers, directors, or trustees of each of the supported organizations? Provide details in Part VI. 3a b Did the organization exercise a substantial degree of direction over the policies, programs, and activities of each of its supported organizations? If "Yes," describe in Part VI the role played by the organization in this regard. 3b
JSA Schedule A (Form 990 or 990-EZ) 2015
5E1230 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 19 KALEIDA HEALTH 16-1533232 Schedule A (Form 990 or 990-EZ) 2015 Page 6 Part V Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations 1 Check here if the organization satisfied the Integral Part Test as a qualifying trust on Nov. 20, 1970. See instructions. All other Type III non-functionally integrated supporting organizations must complete Sections A through E. (B) Current Year Section A - Adjusted Net Income (A) Prior Year (optional) 1 Net short-term capital gain 1 2 Recoveries of prior-year distributions 2 3 Other gross income (see instructions) 3 4 Add lines 1 through 3 4 5 Depreciation and depletion 5 6 Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) 6 7 Other expenses (see instructions) 7 8 Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) 8 (B) Current Year Section B - Minimum Asset Amount (A) Prior Year (optional) 1 Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): a Average monthly value of securities 1a b Average monthly cash balances 1b c Fair market value of other non-exempt-use assets 1c d Total (add lines 1a, 1b, and 1c) 1d e Discount claimed for blockage or other factors (explain in detail in Part VI): 2 Acquisition indebtedness applicable to non-exempt-use assets 2 3 Subtract line 2 from line 1d 3 4 Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). 4 5 Net value of non-exempt-use assets (subtract line 4 from line 3) 5 6 Multiply line 5 by .035 6 7 Recoveries of prior-year distributions 7 8 Minimum Asset Amount (add line 7 to line 6) 8
Section C - Distributable Amount Current Year
1 Adjusted net income for prior year (from Section A, line 8, Column A) 1 2 Enter 85% of line 1 2 3 Minimum asset amount for prior year (from Section B, line 8, Column A) 3 4 Enter greater of line 2 or line 3 4 5 Income tax imposed in prior year 5 6 Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) 6 7 Check here if the current year is the organization's first as a non-functionally-integrated Type III supporting organization (see instructions). Schedule A (Form 990 or 990-EZ) 2015
JSA
5E1231 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 20 KALEIDA HEALTH 16-1533232 Schedule A (Form 990 or 990-EZ) 2015 Page 7 Part V Type III Non-Functionally Integrated 509(a)(3) Supporting Organizations (continued) Section D - Distributions Current Year 1 Amounts paid to supported organizations to accomplish exempt purposes 2 Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity 3 Administrative expenses paid to accomplish exempt purposes of supported organizations 4 Amounts paid to acquire exempt-use assets 5 Qualified set-aside amounts (prior IRS approval required) 6 Other distributions (describe in Part VI). See instructions. 7 Total annual distributions. Add lines 1 through 6. 8 Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions. 9 Distributable amount for 2015 from Section C, line 6 10 Line 8 amount divided by Line 9 amount (ii) (iii) (i) Section E - Distribution Allocations (see instructions) Underdistributions Distributable Excess Distributions Pre-2015 Amount for 2015 1 Distributable amount for 2015 from Section C, line 6 2 Underdistributions, if any, for years prior to 2015 (reasonable cause required-see instructions) 3 Excess distributions carryover, if any, to 2015: a b c d From 2013 e From 2014 f Total of lines 3a through e g Applied to underdistributions of prior years h Applied to 2015 distributable amount i Carryover from 2010 not applied (see instructions) j Remainder. Subtract lines 3g, 3h, and 3i from 3f. 4 Distributions for 2015 from Section D, line 7: $ a Applied to underdistributions of prior years b Applied to 2015 distributable amount c Remainder. Subtract lines 4a and 4b from 4. 5 Remaining underdistributions for years prior to 2015, if any. Subtract lines 3g and 4a from line 2 (if amount greater than zero, see instructions). 6 Remaining underdistributions for 2015. Subtract lines 3h and 4b from line 1 (if amount greater than zero, see instructions). 7 Excess distributions carryover to 2016. Add lines 3j and 4c. 8 Breakdown of line 7: a b c Excess from 2013 d Excess from 2014 e Excess from 2015 Schedule A (Form 990 or 990-EZ) 2015
JSA
5E1232 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 21 KALEIDA HEALTH 16-1533232 Schedule A (Form 990 or 990-EZ) 2015 Page 8 Part VI Supplemental Information. Provide the explanations required by Part II, line 10; Part II, line 17a or 17b; and Part III, line 12. Also complete this part for any additional information. (See instructions).
JSA Schedule A (Form 990 or 990-EZ) 2015 5E1225 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 22 Schedule B Schedule of Contributors OMB No. 1545-0047 (Form 990, 990-EZ, or 990-PF) Attach to Form 990, Form 990-EZ, or Form 990-PF. Department of the Treasury Internal Revenue Service Information about Schedule B (Form 990, 990-EZ, or 990-PF) and its instructions is at www.irs.gov/form990. Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 Organization type (check one):
Filers of: Section:
Form 990 or 990-EZ X3501(c)( ) (enter number) organization
4947(a)(1) nonexempt charitable trust not treated as a private foundation
527 political organization
Form 990-PF 501(c)(3) exempt private foundation
4947(a)(1) nonexempt charitable trust treated as a private foundation
501(c)(3) taxable private foundation
Check if your organization is covered by the General Rule or a Special Rule. Note. Only a section 501(c)(7), (8), or (10) organization can check boxes for both the General Rule and a Special Rule. See instructions.
General Rule
X For an organization filing Form 990, 990-EZ, or 990-PF that received, during the year, contributions totaling $5,000 or more (in money or property) from any one contributor. Complete Parts I and II. See instructions for determining a contributor's total contributions.
Special Rules
For an organization described in section 501(c)(3) filing Form 990 or 990-EZ that met the 33 1/3 % support test of the regulations under sections 509(a)(1) and 170(b)(1)(A)(vi), that checked Schedule A (Form 990 or 990-EZ), Part II, line 13, 16a, or 16b, and that received from any one contributor, during the year, total contributions of the greater of (1) $5,000 or (2) 2% of the amount on (i) Form 990, Part VIII, line 1h, or (ii) Form 990-EZ, line 1. Complete Parts I and II.
For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor, during the year, total contributions of more than $1,000 exclusively for religious, charitable, scientific, literary, or educational purposes, or for the prevention of cruelty to children or animals. Complete Parts I, II, and III.
For an organization described in section 501(c)(7), (8), or (10) filing Form 990 or 990-EZ that received from any one contributor, during the year, contributions exclusively for religious, charitable, etc., purposes, but no such contributions totaled more than $1,000. If this box is checked, enter here the total contributions that were received during the year for an exclusively religious, charitable, etc., purpose. Do not complete any of the parts unless the General Rule applies to this organization because it received nonexclusively religious, charitable, etc., contributions totaling $5,000 or more during the year $ Caution. An organization that is not covered by the General Rule and/or the Special Rules does not file Schedule B (Form 990, 990-EZ, or 990-PF), but it must answer "No" on Part IV, line 2, of its Form 990; or check the box on line H of its Form 990-EZ or on its Form 990-PF, Part I, line 2, to certify that it does not meet the filing requirements of Schedule B (Form 990, 990-EZ, or 990-PF).
For Paperwork Reduction Act Notice, see the Instructions for Form 990, 990-EZ, or 990-PF. Schedule B (Form 990, 990-EZ, or 990-PF) (2015)
JSA 5E1251 2.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 23 Schedule B (Form 990, 990-EZ, or 990-PF) (2015) Page 2 Name of organization KALEIDA HEALTH Employer identification number 16-1533232 Part I Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
1 Person X Payroll $ 23,000. Noncash (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
2 Person X Payroll $ 11,040. Noncash (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
3 Person X Payroll $ 275,514. Noncash (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
4 Person X Payroll $ 38,362. Noncash (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
5 Person X Payroll $ 183,433. Noncash (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
6 Person X Payroll $ 43,825. Noncash (Complete Part II for noncash contributions.)
JSA Schedule B (Form 990, 990-EZ, or 990-PF) (2015) 5E1253 2.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 24 Schedule B (Form 990, 990-EZ, or 990-PF) (2015) Page 2 Name of organization KALEIDA HEALTH Employer identification number 16-1533232 Part I Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
7 Person X Payroll $ 6,288. Noncash (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
8 Person X Payroll $ 18,426. Noncash (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
9 Person X Payroll $ 10,292. Noncash (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
10 Person X Payroll $ 5,778. Noncash (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
11 Person X Payroll $ 35,225. Noncash (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
12 Person X Payroll $ 456,809. Noncash (Complete Part II for noncash contributions.)
JSA Schedule B (Form 990, 990-EZ, or 990-PF) (2015) 5E1253 2.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 25 Schedule B (Form 990, 990-EZ, or 990-PF) (2015) Page 2 Name of organization KALEIDA HEALTH Employer identification number 16-1533232 Part I Contributors (see instructions). Use duplicate copies of Part I if additional space is needed.
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
13 Person X Payroll $ 8,653,280. Noncash (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
14 Person X Payroll $ 5,039,279. Noncash (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
15 Person X Payroll $ 124,300. Noncash (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
16 Person Payroll $ 3,417,726.Noncash X (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
17 Person Payroll $ 936,328.Noncash X (Complete Part II for noncash contributions.)
(a) (b) (c) (d) No. Name, address, and ZIP + 4 Total contributions Type of contribution
Person Payroll $ Noncash (Complete Part II for noncash contributions.)
JSA Schedule B (Form 990, 990-EZ, or 990-PF) (2015) 5E1253 2.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 26 Schedule B (Form 990, 990-EZ, or 990-PF) (2015) Page 3 Name of organization KALEIDA HEALTH Employer identification number 16-1533232 Part II Noncash Property (see instructions). Use duplicate copies of Part II if additional space is needed.
(a) No. (c) (b) (d) from FMV (or estimate) Description of noncash property given Date received Part I (see instructions)
VARIOUS MEDICAL EQUIPTMENT 16
$ 3,417,726.
(a) No. (c) (b) (d) from FMV (or estimate) Description of noncash property given Date received Part I (see instructions)
VARIOUS MEDICAL EQUIPMENT 17
$ 936,328.
(a) No. (c) (b) (d) from FMV (or estimate) Description of noncash property given Date received Part I (see instructions)
$
(a) No. (c) (b) (d) from FMV (or estimate) Description of noncash property given Date received Part I (see instructions)
$
(a) No. (c) (b) (d) from FMV (or estimate) Description of noncash property given Date received Part I (see instructions)
$
(a) No. (c) (b) (d) from FMV (or estimate) Description of noncash property given Date received Part I (see instructions)
$
JSA Schedule B (Form 990, 990-EZ, or 990-PF) (2015) 5E1254 2.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 27 Schedule B (Form 990, 990-EZ, or 990-PF) (2015) Page 4 Name of organization KALEIDA HEALTH Employer identification number 16-1533232 Part III Exclusively religious, charitable, etc., contributions to organizations described in section 501(c)(7), (8), or (10) that total more than $1,000 for the year from any one contributor. Complete columns (a) through (e) and the following line entry. For organizations completing Part III, enter the total of exclusively religious, charitable, etc., contributions of $1,000 or less for the year. (Enter this information once. See instructions.) $ Use duplicate copies of Part III if additional space is needed. (a) No. from (b) Purpose of gift (c) Use of gift (d) Description of how gift is held Part I
(e) Transfer of gift
Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee
(a) No. from (b) Purpose of gift (c) Use of gift (d) Description of how gift is held Part I
(e) Transfer of gift
Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee
(a) No. from (b) Purpose of gift (c) Use of gift (d) Description of how gift is held Part I
(e) Transfer of gift
Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee
(a) No. from (b) Purpose of gift (c) Use of gift (d) Description of how gift is held Part I
(e) Transfer of gift
Transferee's name, address, and ZIP + 4 Relationship of transferor to transferee
JSA Schedule B (Form 990, 990-EZ, or 990-PF) (2015) 5E1255 3.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 28 SCHEDULE C Political Campaign and Lobbying Activities OMB No. 1545-0047 (Form 990 or 990-EZ) For Organizations Exempt From Income Tax Under section 501(c) and section 527 Complete if the organization is described below. Attach to Form 990 or Form 990-EZ. Open to Public Department of the Treasury Information about Schedule C (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990. Internal Revenue Service Inspection If the organization answered "Yes," on Form 990, Part IV, line 3, or Form 990-EZ, Part V, line 46 (Political Campaign Activities), then Section 501(c)(3) organizations: Complete Parts I-A and B. Do not complete Part I-C. Section 501(c) (other than section 501(c)(3)) organizations: Complete Parts I-A and C below. Do not complete Part I-B. Section 527 organizations: Complete Part I-A only. If the organization answered "Yes," on Form 990, Part IV, line 4, or Form 990-EZ, Part VI, line 47 (Lobbying Activities), then Section 501(c)(3) organizations that have filed Form 5768 (election under section 501(h)): Complete Part II-A. Do not complete Part II-B. Section 501(c)(3) organizations that have NOT filed Form 5768 (election under section 501(h)): Complete Part II-B. Do not complete Part II-A. If the organization answered "Yes," on Form 990, Part IV, line 5 (Proxy Tax) (see separate instructions) or Form 990-EZ, Part V, line 35c (Proxy Tax) (see separate instructions), then Section 501(c)(4), (5), or (6) organizations: Complete Part III. Name of organization Employer identification number KALEIDA HEALTH 16-1533232 Part I-A Complete if the organization is exempt under section 501(c) or is a section 527 organization. 1 Provide a description of the organization's direct and indirect political campaign activities in Part IV. 2 Political expenditures $ 3 Volunteer hours
Part I-B Complete if the organization is exempt under section 501(c)(3). 1 Enter the amount of any excise tax incurred by the organization under section 4955 $ 2 Enter the amount of any excise tax incurred by organization managers under section 4955 $ 3 If the organization incurred a section 4955 tax, did it file Form 4720 for this year? Yes No 4a Was a correction made? Yes No b If "Yes," describe in Part IV. Part I-C Complete if the organization is exempt under section 501(c), except section 501(c)(3). 1 Enter the amount directly expended by the filing organization for section 527 exempt function activities $ 2 Enter the amount of the filing organization's funds contributed to other organizations for section 527 exempt function activities $ 3 Total exempt function expenditures. Add lines 1 and 2. Enter here and on Form 1120-POL, line 17b $ 4 Did the filing organization file Form 1120-POL for this year? Yes No 5 Enter the names, addresses and employer identification number (EIN) of all section 527 political organizations to which the filing organization made payments. For each organization listed, enter the amount paid from the filing organization's funds. Also enter the amount of political contributions received that were promptly and directly delivered to a separate political organization, such as a separate segregated fund or a political action committee (PAC). If additional space is needed, provide information in Part IV. (a) Name (b) Address (c) EIN (d) Amount paid from (e) Amount of political filing organization's contributions received and funds. If none, enter -0-. promptly and directly delivered to a separate political organization. If none, enter -0-.
(1)
(2)
(3)
(4)
(5)
(6)
For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Schedule C (Form 990 or 990-EZ) 2015
JSA 5E1264 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 29 Schedule C (Form 990 or 990-EZ) 2015 KALEIDA HEALTH 16-1533232 Page 2 Part II-A Complete if the organization is exempt under section 501(c)(3) and filed Form 5768 (election under section 501(h)). A Check if the filing organization belongs to an affiliated group (and list in Part IV each affiliated group member's name, address, EIN, expenses, and share of excess lobbying expenditures). B Check if the filing organization checked box A and "limited control" provisions apply. Limits on Lobbying Expenditures (a) Filing (b) Affiliated (The term "expenditures" means amounts paid or incurred.) organization's totals group totals 1a Total lobbying expenditures to influence public opinion (grass roots lobbying) b Total lobbying expenditures to influence a legislative body (direct lobbying) c Total lobbying expenditures (add lines 1a and 1b) d Other exempt purpose expenditures e Total exempt purpose expenditures (add lines 1c and 1d) f Lobbying nontaxable amount. Enter the amount from the following table in both columns. If the amount on line 1e, column (a) or (b) is: The lobbying nontaxable amount is: Not over $500,000 20% of the amount on line 1e. Over $500,000 but not over $1,000,000 $100,000 plus 15% of the excess over $500,000. Over $1,000,000 but not over $1,500,000 $175,000 plus 10% of the excess over $1,000,000. Over $1,500,000 but not over $17,000,000 $225,000 plus 5% of the excess over $1,500,000. Over $17,000,000 $1,000,000. g Grassroots nontaxable amount (enter 25% of line 1f) h Subtract line 1g from line 1a. If zero or less, enter -0- i Subtract line 1f from line 1c. If zero or less, enter -0- j If there is an amount other than zero on either line 1h or line 1i, did the organization file Form 4720 reporting section 4911 tax for this year? Yes No 4-Year Averaging Period Under section 501(h) (Some organizations that made a section 501(h) election do not have to complete all of the five columns below. See the separate instructions for lines 2a through 2f.)
Lobbying Expenditures During 4-Year Averaging Period
Calendar year (or fiscal year (a) 2012 (b) 2013 (c) 2014 (d) 2015 (e) Total beginning in)
2a Lobbying nontaxable amount
b Lobbying ceiling amount (150% of line 2a, column (e))
c Total lobbying expenditures
d Grassroots nontaxable amount
e Grassroots ceiling amount (150% of line 2d, column (e))
f Grassroots lobbying expenditures
Schedule C (Form 990 or 990-EZ) 2015
JSA
5E1265 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 30 KALEIDA HEALTH 16-1533232 Schedule C (Form 990 or 990-EZ) 2015 Page 3 Part II-B Complete if the organization is exempt under section 501(c)(3) and has NOT filed Form 5768 (election under section 501(h)). (a) (b) For each "Yes," response on lines 1a through 1i below, provide in Part IV a detailed description of the lobbying activity. Yes No Amount
1 During the year, did the filing organization attempt to influence foreign, national, state or local legislation, including any attempt to influence public opinion on a legislative matter or referendum, through the use of: a Volunteers? X b Paid staff or management (include compensation in expenses reported on lines 1c through 1i)? X c Media advertisements? X d Mailings to members, legislators, or the public? X e Publications, or published or broadcast statements? X f Grants to other organizations for lobbying purposes? X 85,545. g Direct contact with legislators, their staffs, government officials, or a legislative body? X 150,467. h Rallies, demonstrations, seminars, conventions, speeches, lectures, or any similar means? X i Other activities? X j Total. Add lines 1c through 1i 236,012. 2a Did the activities in line 1 cause the organization to be not described in section 501(c)(3)? X b If "Yes," enter the amount of any tax incurred under section 4912 c If "Yes," enter the amount of any tax incurred by organization managers under section 4912 d If the filing organization incurred a section 4912 tax, did it file Form 4720 for this year? X Part III-A Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6). Yes No 1 Were substantially all (90% or more) dues received nondeductible by members? 1 2 Did the organization make only in-house lobbying expenditures of $2,000 or less? 2 3 Did the organization agree to carry over lobbying and political expenditures from the prior year? 3 Part III-B Complete if the organization is exempt under section 501(c)(4), section 501(c)(5), or section 501(c)(6) and if either (a) BOTH Part III-A, lines 1 and 2, are answered "No," OR (b) Part III-A, line 3, is answered "Yes." 1 Dues, assessments and similar amounts from members 1 2 Section 162(e) nondeductible lobbying and political expenditures (do not include amounts of political expenses for which the section 527(f) tax was paid). a Current year 2a b Carryover from last year 2b c Total 2c 3 Aggregate amount reported in section 6033(e)(1)(A) notices of nondeductible section 162(e) dues 3 4 If notices were sent and the amount on line 2c exceeds the amount on line 3, what portion of the excess does the organization agree to carryover to the reasonable estimate of nondeductible lobbying and political expenditure next year? 4 5 Taxable amount of lobbying and political expenditures (see instructions) 5 Part IV Supplemental Information Provide the descriptions required for Part I-A, line 1; Part I-B, line 4; Part I-C, line 5; Part II-A (affiliated group list); Part II-A, lines 1 and 2 (see instructions); and Part II-B, line 1. Also, complete this part for any additional information.
SEE PAGE 4
JSA Schedule C (Form 990 or 990-EZ) 2015 5E1266 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 31 KALEIDA HEALTH 16-1533232
Schedule C (Form 990 or 990-EZ) 2015 Page 4 Part IV Supplemental Information (continued)
GRANTS TO OTHER ORGANIZATIONS & DIRECT CONTACT WITH LEGISLATIVE BODY
SCHEDULE C, PART II-B, QUESTIONS 1F AND 1G
THE AMOUNT REFLECTED FOR PART II-B, QUESTION 1F REPRESENTS THE PORTION OF
THE DUES PAID TO THE GREATER NEW YORK HOSPITAL ASSOCIATION ATTRIBUTABLE
TO LOBBYING ACTIVITIES. THE AMOUNT REFLECTED FOR PART II-B, QUESTION 1G
REPRESENTS PAYMENTS MADE TO ORGANIZATIONS IN AN EFFORT TO ADVOCATE ON THE
ORGANIZATION'S BEHALF AT THE NEW YORK STATE AND FEDERAL LEVELS AS IT
SPECIFICALLY RELATES TO HEALTH CARE LEGISLATION AND REGULATORY ISSUES.
JSA Schedule C (Form 990 or 990-EZ) 2015
5E1500 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 32 SCHEDULE D OMB No. 1545-0047 (Form 990) Supplemental Financial Statements Complete if the organization answered "Yes" on Form 990, Part IV, line 6, 7, 8, 9, 10, 11a, 11b, 11c, 11d, 11e, 11f, 12a, or 12b. Attach to Form 990. Open to Public Department of the Treasury Internal Revenue Service Information about Schedule D (Form 990) and its instructions is at www.irs.gov/form990. Inspection Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 Part I Organizations Maintaining Donor Advised Funds or Other Similar Funds or Accounts. Complete if the organization answered "Yes" on Form 990, Part IV, line 6. (a) Donor advised funds (b) Funds and other accounts 1 Total number at end of year 2 Aggregate value of contributions to (during year) 3 Aggregate value of grants from (during year) 4 Aggregate value at end of year 5 Did the organization inform all donors and donor advisors in writing that the assets held in donor advised funds are the organization's property, subject to the organization's exclusive legal control? Yes No 6 Did the organization inform all grantees, donors, and donor advisors in writing that grant funds can be used only for charitable purposes and not for the benefit of the donor or donor advisor, or for any other purpose conferring impermissible private benefit? Yes No Part II Conservation Easements. Complete if the organization answered "Yes" on Form 990, Part IV, line 7. 1 Purpose(s) of conservation easements held by the organization (check all that apply). Preservation of land for public use (e.g., recreation or education) Preservation of a historically important land area Protection of natural habitat Preservation of a certified historic structure Preservation of open space 2 Complete lines 2a through 2d if the organization held a qualified conservation contribution in the form of a conservation easement on the last day of the tax year. Held at the End of the Tax Year a Total number of conservation easements 2a b Total acreage restricted by conservation easements 2b c Number of conservation easements on a certified historic structure included in (a) 2c d Number of conservation easements included in (c) acquired after 8 /17/06, and not on a historic structure listed in the National Register 2d 3 Number of conservation easements modified, transferred, released, extinguished, or terminated by the organization during the tax year 4 Number of states where property subject to conservation easement is located 5 Does the organization have a written policy regarding the periodic monitoring, inspection, handling of violations, and enforcement of the conservation easements it holds? Yes No 6 Staff and volunteer hours devoted to monitoring, inspecting, handling of violations, and enforcing conservation easements during the year 7 Amount of expenses incurred in monitoring, inspecting, handling of violations, and enforcing conservation easements during the year $ 8 Does each conservation easement reported on line 2(d) above satisfy the requirements of section 170(h)(4)(B)(i) and section 170(h)(4)(B)(ii)? Yes No 9 In Part XIII, describe how the organization reports conservation easements in its revenue and expense statement, and balance sheet, and include, if applicable, the text of the footnote to the organization’s financial statements that describes the organization's accounting for conservation easements. Part III Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets. Complete if the organization answered "Yes" on Form 990, Part IV, line 8. 1a If the organization elected, as permitted under SFAS 116 (ASC 958), not to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide, in Part XIII, the text of the footnote to its financial statements that describes these items. b If the organization elected, as permitted under SFAS 116 (ASC 958), to report in its revenue statement and balance sheet works of art, historical treasures, or other similar assets held for public exhibition, education, or research in furtherance of public service, provide the following amounts relating to these items: (i) Revenue included in Form 990, Part VIII, line 1 $ (ii) Assets included in Form 990, Part X $ 2 If the organization received or held works of art, historical treasures, or other similar assets for financial gain, provide the following amounts required to be reported under SFAS 116 (ASC 958) relating to these items: a Revenue included in Form 990, Part VIII, line 1 $ b Assets included in Form 990, Part X $ For Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule D (Form 990) 2015 JSA 5E1268 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 33 KALEIDA HEALTH 16-1533232 Schedule D (Form 990) 2015 Page 2 Part III Organizations Maintaining Collections of Art, Historical Treasures, or Other Similar Assets (continued) 3 Using the organization's acquisition, accession, and other records, check any of the following that are a significant use of its collection items (check all that apply): a Public exhibition d Loan or exchange programs b Scholarly research e Other c Preservation for future generations 4 Provide a description of the organization's collections and explain how they further the organization's exempt purpose in Part XIII. 5 During the year, did the organization solicit or receive donations of art, historical treasures, or other similar assets to be sold to raise funds rather than to be maintained as part of the organization's collection? Yes No Part IV Escrow and Custodial Arrangements. Complete if the organization answered “Yes” on Form 990, Part IV, line 9, or reported an amount on Form 990, Part X, line 21. 1a Is the organization an agent, trustee, custodian or other intermediary for contributions or other assets not included on Form 990, Part X? Yes No b If "Yes," explain the arrangement in Part XIII and complete the following table: Amount c Beginning balance 1c d Additions during the year 1d e Distributions during the year 1e f Ending balance 1f 2a Did the organization include an amount on Form 990, Part X, line 21, for escrow or custodial account liability? Yes No b If "Yes," explain the arrangement in Part XIII. Check here if the explanation has been provided on Part XIII Part V Endowment Funds. Complete if the organization answered “Yes” on Form 990, Part IV, line 10. (a) Current year (b) Prior year (c) Two years back (d) Three years back (e) Four years back 1a Beginning of year balance 30,738,989. 30,087,437. 28,644,541. 46,995,623. 72,587,179. b Contributions 1,435,796. 1,656,821. 1,589,183. 3,133,756. 5,877,436. c Net investment earnings, gains, and losses -1,046,152. 850,732. 1,819,135. 2,880,650. 28,660. d Grants or scholarships e Other expenditures for facilities and programs 1,306,974. 1,856,001. 1,965,422. 24,365,488. 31,497,652. f Administrative expenses g End of year balance 29,821,659. 30,738,989. 30,087,437. 28,644,541. 46,995,623. 2 Provide the estimated percentage of the current year end balance (line 1g, column (a)) held as: a Board designated or quasi-endowment 73.2200 % b Permanent endowment % c Temporarily restricted endowment 26.7800 % The percentages on lines 2a, 2b, and 2c should equal 100%. 3a Are there endowment funds not in the possession of the organization that are held and administered for the organization by: Yes No (i) unrelated organizations 3a(i) X (ii) related organizations 3a(ii) X b If "Yes" on line 3a(ii), are the related organizations listed as required on Schedule R? 3b X 4 Describe in Part XIII the intended uses of the organization's endowment funds. Part VI Land, Buildings, and Equipment. Complete if the organization answered "Yes" on Form 990, Part IV, line 11a. See Form 990, Part X, line 10. Description of property (a) Cost or other basis (b) Cost or other basis (c) Accumulated (d) Book value (investment) (other) depreciation 1a Land 6,713,868. 6,713,868. b Buildings 502,000,914. 333,643,141. 168,357,773. c Leasehold improvements d Equipment 1038865298. 737,835,722. 301,029,576. e Other 15,383,196. 9,551,463. 5,831,733. Total. Add lines 1a through 1e. (Column (d) must equal Form 990, Part X, column (B), line 10c.) 481,932,950. Schedule D (Form 990) 2015
JSA 5E1269 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 34 KALEIDA HEALTH 16-1533232 Schedule D (Form 990) 2015 Page 3 Part VII Investments - Other Securities. Complete if the organization answered "Yes" on Form 990, Part IV, line 11b. See Form 990, Part X, line 12. (a) Description of security or category (b) Book value (c) Method of valuation: (including name of security) Cost or end-of-year market value (1) Financial derivatives (2) Closely-held equity interests (3) Other ATTACHMENT 1 (A) INTECH RISK-MANAGED L CAP FUND 3,024,282. FMV (B) WTC CTF RE VALUE (PURCH 4/06) 4,377,975. FMV (C) BENCHMARK PLUS INST PART L CAP 5,063,519. FMV (D) WTC CIF OPPORTUNISTIC FUND 9,317,831. FMV (E) KALEIDA MIT COMMON FUND LP 29,068. FMV (F) COMMON CAP VENTURE PTNRS VI 65,213. FMV (G) COMMON FND CAP PRIVATE EQ P V 71,703. FMV (H) KALEIDA MIT REALTY LP 264,718. FMV Total. (Column (b) must equal Form 990, Part X, col. (B) line 12.) 66,484,188. Part VIII Investments - Program Related. Complete if the organization answered "Yes" on Form 990, Part IV, line 11c. See Form 990, Part X, line 13. (a) Description of investment (b) Book value (c) Method of valuation: Cost or end-of-year market value (1) (2) (3) (4) (5) (6) (7) (8) (9) Total. (Column (b) must equal Form 990, Part X, col. (B) line 13.) Part IX Other Assets. Complete if the organization answered "Yes" on Form 990, Part IV, line 11d. See Form 990, Part X, line 15. (a) Description (b) Book value (1) DEFERRED FINANCING 11,239,178. (2) INTEREST IN NET ASSETS OF FDNS 149,604,705. (3) OTHER RECEIVABLES 25,228,242. (4) OTHER ASSETS 24,714,326. (5) INSURANCE RECOVERIES REC. 145,375. (6) ESTIMATED 3RD PARTY PAYOR REC 21,903,766. (7) (8) (9) Total. (Column (b) must equal Form 990, Part X, col. (B) line 15.) 232,835,592. Part X Other Liabilities. Complete if the organization answered "Yes" on Form 990, Part IV, line 11e or 11f. See Form 990, Part X, line 25. 1. (a) Description of liability (b) Book value (1) Federal income taxes (2) DUE TO THIRD PARTY PAYORS 22,303,974. (3) SELF INSURANCE LIABILITY 153,552,721. (4) OTHER LIABILITIES 13,548,116. (5) PENSION LIABILITY 259,672,223. (6) ASSET RETIREMENT OBLIGATIONS 13,217,735. (7) CAPITAL LEASE OBLIGATIONS 5,408,980. (8) CONSTRUCTION PAYABLE 16,979,193. (9) Total. (Column (b) must equal Form 990, Part X, col. (B) line 25.) 484,682,942. 2. Liability for uncertain tax positions. In Part XIII, provide the text of the footnote to the organization's financial statements that reports the organization's liability for uncertain tax positions under FIN 48 (ASC 740). Check here if the text of the footnote has been provided in Part XIII X JSA 5E1270 1.000 Schedule D (Form 990) 2015 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 35 KALEIDA HEALTH 16-1533232 Schedule D (Form 990) 2015 Page 4 Part XI Reconciliation of Revenue per Audited Financial Statements With Revenue per Return. Complete if the organization answered "Yes" on Form 990, Part IV, line 12a. 1 Total revenue, gains, and other support per audited financial statements 1 1201085440. 2 Amounts included on line 1 but not on Form 990, Part VIII, line 12: a Net unrealized gains (losses) on investments 2a -7,089,586. b Donated services and use of facilities 2b c Recoveries of prior year grants 2c d Other (Describe in Part XIII.) 2d -140,471. e Add lines 2a through 2d 2e -7,230,057. 3 Subtract line 2e from line 1 3 1208315497. 4 Amounts included on Form 990, Part VIII, line 12, but not on line 1: a Investment expenses not included on Form 990, Part VIII, line 7b 4a b Other (Describe in Part XIII.) 4b 11,869,382. c Add lines 4a and 4b 4c 11,869,382. 5 Total revenue. Add lines 3 and 4c. (This must equal Form 990, Part I, line 12.) 5 1220184879. Part XII Reconciliation of Expenses per Audited Financial Statements With Expenses per Return. Complete if the organization answered "Yes" on Form 990, Part IV, line 12a. 1 Total expenses and losses per audited financial statements 1 1182813943. 2 Amounts included on line 1 but not on Form 990, Part IX, line 25: a Donated services and use of facilities 2a b Prior year adjustments 2b c Other losses 2c d Other (Describe in Part XIII.) 2d e Add lines 2a through 2d 2e 3 Subtract line 2e from line 1 3 1182813943. 4 Amounts included on Form 990, Part IX, line 25, but not on line 1: a Investment expenses not included on Form 990, Part VIII, line 7b 4a b Other (Describe in Part XIII.) 4b 1,306,972. c Add lines 4a and 4b 4c 1,306,972. 5 Total expenses. Add lines 3 and 4c. (This must equal Form 990, Part I, line 18.) 5 1184120915. Part XIII Supplemental Information. Provide the descriptions required for Part II, lines 3, 5, and 9; Part III, lines 1a and 4; Part IV, lines 1b and 2b; Part V, line 4; Part X, line 2; Part XI, lines 2d and 4b; and Part XII, lines 2d and 4b. Also complete this part to provide any additional information. SEE PAGE 5
JSA Schedule D (Form 990) 2015 5E1271 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 36 Schedule D (Form 990) 2015 KALEIDA HEALTH 16-1533232 Page 5 Part XIII Supplemental Information (continued)
INTENDED USE OF ENDOWMENTS:
SCHEDULE D, PART V, QUESTION 4
THE FOLLOWING ARE THE INTENDED USES OF THE ORGANIZATION'S ENDOWMENT
FUNDS:
1) CAPITAL EXPANSION AND IMPROVEMENT
2) ADVANCEMENT OF MEDICAL EDUCATION AND RESEARCH AND HEALTH CARE
SERVICES
3) SUPPORT PEDIATRIC HEALTH CARE SERVICES
FIN 48 FOOTNOTE:
SCHEDULE D, PART X, QUESTION 2
KALEIDA RECOGNIZES INCOME TAX POSITIONS WHEN IT IS MORE-LIKELY THAN-NOT
THAT THE POSITION WILL BE SUSTAINABLE BASED ON THE MERITS OF THE
POSITION. MANAGEMENT HAS CONCLUDED THAT THERE ARE NO MATERIAL UNCERTAIN
TAX POSITIONS THAT NEED TO BE RECORDED.
RECONCILIATION OF REVENUE PER AFS WITH REVENUE PER RETURN:
OTHER REVENUE INCLUDED IN AFS, NOT INCLUDED IN 990:
LESS: MINORITY INTEREST IN SUBSIDIARY SHOWN AS A REDUCTION IN GAINS IN
AFS (140,471)
RECONCILIATION OF REVENUE PER AFS WITH REVENUE PER RETURN:
OTHER REVENUE INCLUDED ON 990, NOT IN AFS:
CONTRIBUTIONS FOR CAPITAL ACQUISITIONS 9,921,413
RESTRICTED CONTRIBUTIONS 1,435,796
RESTRICTED INVESTMENT INCOME 512,173
Schedule D (Form 990) 2015 JSA 5E1226 1.000
6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 37 Schedule D (Form 990) 2015 KALEIDA HEALTH 16-1533232 Page 5 Part XIII Supplemental Information (continued)
TOTAL 11,869,382
RECONCILIATION OF EXPENSES PER AFS WITH EXPENSES PER RETURN:
SCHEDULE D, PART XII, LINE 4B
OTHER EXPENSES INCLUDED ON 990, NOT IN AFS
NET ASSETS RELEASED FROM RESTRICTIONS 1,306,972 ATTACHMENT 1 SCHEDULE D, PART VII - INVESTMENTS - OTHER SECURITIES COST DESCRIPTION BOOK VALUE OR FMV
KALEIDA SI REALTY LP 1,073,203. FMV
ROBECO GLOBAL EMERGING MARKETS 3,713,260. FMV
AQR GLOBAL RISK 7,360,079. FMV
PANAGORA RISK PARITY TOTAL RET 7,525,657. FMV
ORCHARD LANDMARK LTD PTNRS 831,759. FMV
ABERDEEN EMERGING MARKETS 2,807,946. FMV
PERMAL FIXED INCOME HOLDING 3,196,094. FMV
CRESTLINE OFFSHORE FUND 1,148,172. FMV
KAYNE ANDERSON INST LTD PTSHP 2,645,014. FMV
MONROE CAP LTD PTSHP 632,163. FMV
GAM UNCONSTRAINED FUND 6,414,249. FMV
EARNEST PARTNERS INTERNATIONAL 4,988,728. FMV
CVI CREDIT VALUE FUND B III 220,170. FMV
SYMPHONY LONG-SHORT CREDIT FUN 342,677. FMV
WHITEBOX MULTI STRAT FD LTD 171,339. FMV
PROPRIETARY MATRIX SP HEDGE FD 342,677. FMV
Schedule D (Form 990) 2015 JSA 5E1226 1.000
6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 38 Schedule D (Form 990) 2015 KALEIDA HEALTH 16-1533232 Page 5 Part XIII Supplemental Information (continued) ATTACHMENT 1 (CONT'D) SCHEDULE D, PART VII - INVESTMENTS - OTHER SECURITIES COST DESCRIPTION BOOK VALUE OR FMV
CANYON PRI 428,346. FMV
SELECT EQUITY GROUP PRI 428,346. FMV
TOTALS 66,484,188.
Schedule D (Form 990) 2015 JSA 5E1226 1.000
6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 39 SCHEDULE F Statement of Activities Outside the United States OMB No. 1545-0047 (Form 990) Complete if the organization answered "Yes" on Form 990, Part IV, line 14b, 15, or 16. Attach to Form 990. Open to Public Department of the Treasury Information about Schedule F (Form 990) and its instructions is at www.irs.gov/form990. Internal Revenue Service Inspection Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 Part I General Information on Activities Outside the United States. Complete if the organization answered "Yes" on Form 990, Part IV, line 14b. 1 For grantmakers. Does the organization maintain records to substantiate the amount of its grants and other assistance, the grantees' eligibility for the grants or assistance, and the selection criteria used to award the grants or assistance? Yes No
2 For grantmakers. Describe in Part V the organization's procedures for monitoring the use of its grants and other assistance outside the United States.
3 Activities per Region. (The following Part I, line 3 table can be duplicated if additional space is needed.) (a) Region (b) Number of (c) Number of (d) Activities conducted in (e) If activity listed in (d) is (f) Total offices in the employees, region (by type) (e.g., a program service, expenditures for region agents, and fundraising, program services, describe specific type of and investments independent investments, service(s) in region in region contractors grants to recipients in region located in the region)
(1) CENTRAL AMERICA/CARIBBEAN INVESTMENTS 27,610,296.
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17) 3a Sub-total 27,610,296. b Total from continuation sheets to Part I c Totals (add lines 3a and 3b) 27,610,296. ForPaperworkReductionActNotice,seetheInstructionsforForm990. ScheduleF(Form 990) 2015 JSA 5E1274 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 40 KALEIDA HEALTH 16-1533232 Schedule F (Form 990) 2015 Page 2 Part II Grants and Other Assistance to Organizations or Entities Outside the United States. Complete if the organization answered "Yes" on Form 990, Part IV, line 15, for any recipient who received more than $5,000. Part II can be duplicated if additional space is needed. (i) Method of 1 (a) Name of (b) IRS code (c) Region (d) Purpose of (e) Amount of (f) Manner of (g) Amount of (h) Description valuation cash non-cash of non-cash organization section and EIN grant cash grant (book, FMV, (if applicable) disbursement assistance assistance appraisal, other)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
2 Enter total number of recipient organizations listed above that are recognized as charities by the foreign country, recognized as tax-exempt by the IRS, or for which the grantee or counsel has provided a section 501(c)(3) equivalency letter 3 Enter total number of other organizations or entities Schedule F (Form 990) 2015
JSA 5E1275 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 41 KALEIDA HEALTH 16-1533232 Schedule F (Form 990) 2015 Page 3 Part III Grants and Other Assistance to Individuals Outside the United States. Complete if the organization answered "Yes" on Form 990, Part IV, line 16. Part III can be duplicated if additional space is needed. (e) Manner of (f) Amount of (g) Description (h) Method of (a) Type of grant or assistance (b) Region (c) Number of (d) Amount of cash non-cash of non-cash valuation recipients cash grant disbursement assistance assistance (book, FMV, appraisal, other)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
(17)
(18) Schedule F (Form 990) 2015
JSA 5E1276 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 42 KALEIDA HEALTH 16-1533232 Schedule F (Form 990) 2015 Page 4 Part IV Foreign Forms
1 Was the organization a U.S. transferor of property to a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 926, Return by a U.S. Transferor of Property to a Foreign Corporation (see Instructions for Form 926) X Yes No
2 Did the organization have an interest in a foreign trust during the tax year? If "Yes," the organization may be required to separately file Form 3520, Annual Return To Report Transactions With Foreign Trusts and Receipt of Certain Foreign Gifts, and/or Form 3520-A, Annual Information Return of Foreign Trust With a U.S. Owner (see Instructions for Forms 3520 and 3520-A; do not file with Form 990) Yes No
3 Did the organization have an ownership interest in a foreign corporation during the tax year? If "Yes," the organization may be required to file Form 5471, Information Return of U.S. Persons With Respect to Certain Foreign Corporations (see Instructions for Form 5471) X Yes No
4 Was the organization a direct or indirect shareholder of a passive foreign investment company or a qualified electing fund during the tax year? If "Yes," the organization may be required to file Form 8621, Information Return by a Shareholder of a Passive Foreign Investment Company or Qualified Electing Fund (see Instructions for Form 8621) Yes No
5 Did the organization have an ownership interest in a foreign partnership during the tax year? If "Yes," the organization may be required to file Form 8865, Return of U.S. Persons With Respect to Certain Foreign Partnerships (see Instructions for Form 8865) X Yes No
6 Did the organization have any operations in or related to any boycotting countries during the tax year? If "Yes," the organization may be required to separately file Form 5713, International Boycott Report (see Instructions for Form 5713; do not file with Form 990) Yes No
Schedule F (Form 990) 2015
JSA
5E1277 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 43 KALEIDA HEALTH 16-1533232 Schedule F (Form 990) 2015 Page 5 Part V Supplemental Information Complete this part to provide the information required by Part I, line 2 (monitoring of funds); Part I, line 3, column (f) (accounting method; amounts of investments vs. expenditures per region); Part II, line 1 (accounting method); Part III (accounting method); and Part III, column (c) (estimated number of recipients), as applicable. Also complete this part to provide any additional information (see instructions).
JSA Schedule F (Form 990) 2015
5E1502 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 44 SCHEDULE H Hospitals OMB No. 1545-0047 (Form 990) Complete if the organization answered "Yes" on Form 990, Part IV, question 20. Attach to Form 990. Open to Public Department of the Treasury Internal Revenue Service Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990. Inspection Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 Part I Financial Assistance and Certain Other Community Benefits at Cost Yes No 1a Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a 1a X b If "Yes," was it a written policy? 1b X 2 If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year. X Applied uniformly to all hospital facilities Applied uniformly to most hospital facilities Generally tailored to individual hospital facilities 3 Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year. a Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care? If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care: 3a X 100% 150%X 200% Other % b Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate which of the following was the family income limit for eligibility for discounted care: 3b X 200% 250% 300% 350%X 400% Other % c If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care. 4 Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? 4 X 5a Did the organization budget amounts for free or discounted care provided under its financial assistance policy during the tax year? 5a X b If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? 5b X c If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discounted care to a patient who was eligible for free or discounted care? 5c X 6a Did the organization prepare a community benefit report during the tax year? 6a X b If "Yes," did the organization make it available to the public? 6b Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H. 7 Financial Assistance and Certain Other Community Benefits at Cost Financial Assistance and (a) Number of (b) Persons (c) Total community (d) Direct offsetting (e) Net community (f) Percent activities or revenue benefit expense Means-Tested Government programs served benefit expense of total (optional) expense Programs (optional) a Financial Assistance at cost (from Worksheet 1) 12,162,811. 7,403,369. 4,759,442. .40 b Medicaid (from Worksheet 3, column a) 337,945,586. 241,550,314. 96,395,272. 8.14 c Costs of other means-tested government programs (from Worksheet3,columnb) d Total Financial Assistance and Means-Tested Government Programs 350,108,397. 248,953,683. 101,154,714. 8.54 Other Benefits e Community health improvement services and community benefit 5,322,913. 5,322,913. .45 operations (from Worksheet 4) f Health professions education (from Worksheet 5) 51,289,838. 22,280,945. 29,008,893. 2.45 g Subsidized health services (from Worksheet 6) 43,427,214. 11,368,138. 32,059,076. 2.71 h Research (from Worksheet 7) i Cash and in-kind contributions for community benefit (from Worksheet 8) 79,500. 79,500. .01 j Total. Other Benefits 100,119,465. 33,649,083. 66,470,382. 5.62 k Total. Add lines 7d and 7j 450,227,862. 282,602,766. 167,625,096. 14.16 For Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule H (Form 990) 2015 JSA 5E1284 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 45 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 2 Part II Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of (b) Persons (c) Total community (d) Direct offsetting (e) Net community (f) Percent of activities or served building expense revenue building expense total expense programs (optional) (optional)
1 Physical improvements and housing 2 Economic development 3 Community support 4 Environmental improvements 5 Leadership development and
training for community members 6 Coalition building 7 Community health improvement advocacy 147 30124 84,698. 84,698. .01 8 Workforce development 9 Other 10 Total 147 30124 84,698. 84,698. .01 Part III Bad Debt, Medicare, & Collection Practices Section A. Bad Debt Expense Yes No 1 Did the organization report bad debt expense in accordance with Healthcare Financial Management Association Statement No. 15? 1 X 2 Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount 2 8,180,568. 3 Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit 3 541,145. 4 Provide in Part VI the text of the footnote to the organization's financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements. Section B. Medicare 5 Enter total revenue received from Medicare (including DSH and IME) 5 180,379,874. 6 Enter Medicare allowable costs of care relating to payments on line 5 6 164,173,474. 7 Subtract line 6 from line 5. This is the surplus (or shortfall) 7 16,206,400. 8 Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit. Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6. Check the box that describes the method used: Cost accounting systemX Cost to charge ratio Other Section C. Collection Practices 9a Did the organization have a written debt collection policy during the tax year? 9a X b If "Yes," did the organization's collection policy that applied to the largest number of its patients during the tax year contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI 9b X Part IV Management Companies and Joint Ventures (owned 10% or more by officers, directors, trustees, key employees, and physicians - see instructions) (a) Name of entity (b) Description of primary (c) Organization's (d) Officers, directors, (e) Physicians' activity of entity profit % or stock trustees, or key profit % or stock ATTACHMENT 1 ownership % employees' profit % ownership % or stock ownership % 1MFSC, LLC PHYSICIAN SERVICES 55.29740 44.70260 2COMMUNITY MEDICAL PHYSICIAN SERVICES 100.00000 3GENERAL PHYSICIANS PHYSICIAN SERVICES 100.00000 4HARLEM ROAD LEASING MRI EQUIPMENT LEASING 50.00000 5AMTON IMAGING, LLC HEALTH CARE SERVICES 50.00000 6PARK CLUB LANE, LLC HEALTH CARE SERVICES 30.00000 7WNY HEALTHENET, LLC HEALTH CARE SERVICES 14.28572 8SITE E, LLC REAL ESTATE LEASING CO 50.16010 9ALTUS MANAGEMENT GROUP PURCHASING ORGANIZATION 52.16700 10SOUTHTOWNS IMAGING IMAGING EQUIPMENT LEASING 70.00000 11COLLABORATIVE CARE HEALTH CARE SERVICES 60.00000 12GL MEDICAL BILLING MEDICAL BILLING 50.00000 13GREAT LAKES PHYS, PC PHYSICIAN SERVICES 100.00000 JSA 5E1285 1.000 Schedule H (Form 990) 2015 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 46 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 3 Part V Facility Information Section A. Hospital Facilities hospital Licensed surgical & medical General hospital Children's hospital Teaching hospital access Critical facility Research hours ER-24 ER-other (list in order of size, from largest to smallest - see instructions) How many hospital facilities did the organization operate during the tax year? 4 Name, address, primary website address, and state license number (and if a group return, the name and EIN of the Facility subordinate hospital organization that operates the hospital reporting group facility) Other (describe) 1 BUFFALO GENERAL MEDICAL CENTER 100 HIGH STREET BUFFALO NY 14203 WWW.KALEIDAHEALTH.ORG 1401014H X X X X A 2 WOMEN & CHILDREN'S HOSPITAL OF BUFFAL 219 BRYANT STREET BUFFALO NY 14222 WWW.KALEIDAHEALTH.ORG 1401014H X X X X X A 3 MILLARD FILLMORE SUBURBAN HOSPITAL 1540 MAPLE ROAD WILLIAMSVILLE NY 14221 WWW.KALEIDAHEALTH.ORG 1401014H X X X X A 4 DEGRAFF MEMORIAL HOSPITAL 445 TREMONT STREET NORTH TONAWANDA NY 14120 WWW.KALEIDAHEALTH.ORG 1401014H X X X X A 5
6
7
8
9
10
JSA Schedule H (Form 990) 2015 5E1286 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 47 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 4 Part V Facility Information (continued) Section B. Facility Policies and Practices (Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
Name of hospital facility or letter of facility reporting group GROUP A Line number of hospital facility, or line numbers of hospital facilities in a facility reporting group (from Part V, Section A): 1-4 Yes No Community Health Needs Assessment 1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year? 1 X 2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If "Yes," provide details of the acquisition in Section C 2 X 3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12 3 X If "Yes," indicate what the CHNA report describes (check all that apply): a X A definition of the community served by the hospital facility b X Demographics of the community c X Existing health care facilities and resources within the community that are available to respond to the health needs of the community d X How data was obtained e X The significant health needs of the community f X Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups g X The process for identifying and prioritizing community health needs and services to meet the community health needs h X The process for consulting with persons representing the community's interests i Information gaps that limit the hospital facility's ability to assess the community's health needs j Other (describe in Section C) 4 Indicate the tax year the hospital facility last conducted a CHNA: 20 13 5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted 5 X 6a Was the hospital facility's CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C 6a X b Was thehospital facility's CHNA conducted with one or more organizations other than hospital facilities? If "Yes," list the other organizations in Section C 6b X 7 Did the hospital facility make its CHNA report widely available to the public? 7 X If "Yes," indicate how the CHNA report was made widely available (check all that apply): a XHospital facility's website (list url): WWW.KALEIDAHEALTH.ORG/COMMUNITY b Other website (list url): c Made a paper copy available for public inspection without charge at the hospital facility d X Other (describe in Section C) 8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs identified through its most recently conducted CHNA? If "No," skip to line 11 8 X 9 Indicate the tax year the hospital facility last adopted an implementation strategy: 2014 10 Is the hospital facility's most recently adopted implementation strategy posted on a website? 10 X a If "Yes," (list url):WWW.KALEIDAHEALTH.ORG/COMMUNITY b If "No," is the hospital facility's most recently adopted implementation strategy attached to this return? 10b X 11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed. 12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)? 12a X b If "Yes" to line 12a, did the organization file Form 4720 to report the section 4959 excise tax? 12b c If "Yes" to line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $ Schedule H (Form 990) 2015 JSA 5E1287 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 48 Schedule H (Form 990) 2015 KALEIDA HEALTH 16-1533232 Page 5 Part V Facility Information (continued) Financial Assistance Policy (FAP)
Name of hospital facility or letter of facility reporting group GROUP A Yes No Did the hospital facility have in place during the tax year a written financial assistance policy that: 13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 X If "Yes," indicate the eligibility criteria explained in the FAP: a X Federal poverty guidelines (FPG), with FPG family income limit for eligibility for free care of 200.0000 % and FPG family income limit for eligibility for discounted care of 200.0000 % b Income level other than FPG (describe in Section C) c X Asset level d Medical indigency e X Insurance status f X Underinsurance status g Residency h Other (describe in Section C) 14 Explained the basis for calculating amounts charged to patients? 14 X 15 Explained the method for applying for financial assistance? 15 X If "Yes," indicate how the hospital facility's FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply): a X Described the information the hospital facility may require an individual to provide as part of his or her application b X Described the supporting documentation the hospital facility may require an individual to submit as part of his or her application c X Provided the contact information of hospital facility staff who can provide an individual with information about the FAP and FAP application process d Provided the contact information of nonprofit organizations or government agencies that may be sources of assistance with FAP applications e Other (describe in Section C) 16 Included measures to publicize the policy within the community served by the hospital facility? 16 X If "Yes," indicate how the hospital facility publicized the policy (check all that apply): a XThe FAP was widely available on a website (list url): WWW.KALEIDAHEALTH.ORG b XThe FAP application form was widely available on a website (list url): WWW.KALEIDAHEALTH.ORG c X A plain language summary of the FAP was widely available on a website (list url): WWW.KALEIDAHEALTH.ORG d X The FAP was available upon request and without charge (in public locations in the hospital facility and by mail) e X The FAP application form was available upon request and without charge (in public locations in the hospital facility and by mail) f X A plain language summary of the FAP was available upon request and without charge (in public locations in the hospital facility and by mail) g X Notice of availability of the FAP was conspicuously displayed throughout the hospital facility h X Notified members of the community who are most likely to require financial assistance about availability of the FAP i X Other (describe in Section C) Billing and Collections 17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon non-payment? 17 X 18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual's eligibility under the facility's FAP: a Reporting to credit agency(ies) b Selling an individual's debt to another party c X Actions that require a legal or judicial process d X Other similar actions (describe in Section C) e None of these actions or other similar actions were permitted Schedule H (Form 990) 2015
JSA
5E1323 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 49 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 6 Part V Facility Information (continued)
Name of hospital facility or letter of facility reporting group GROUP A Yes No 19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual's eligibility under the facility's FAP? 19 X If "Yes," check all actions in which the hospital facility or a third party engaged: a Reporting to credit agency(ies) b Selling an individual's debt to another party c Actions that require a legal or judicial process d Other similar actions (describe in Section C) 20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19 (check all that apply): a Notified individuals of the financial assistance policy on admission b Notified individuals of the financial assistance policy prior to discharge c Notified individuals of the financial assistance policy in communications with the individuals regarding the individuals' bills d Documented its determination of whether individuals were eligible for financial assistance under the hospital facility's financial assistance policy e Other (describe in Section C) f X None of these efforts were made Policy Relating to Emergency Medical Care 21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility's financial assistance policy? 21 X If "No," indicate why: a The hospital facility did not provide care for any emergency medical conditions b The hospital facility's policy was not in writing c The hospital facility limited who was eligible to receive care for emergency medical conditions (describe in Section C) d Other (describe in Section C) Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals) 22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care. a The hospital facility used its lowest negotiated commercial insurance rate when calculating the maximum amounts that can be charged b The hospital facility used the average of its three lowest negotiated commercial insurance rates when calculating the maximum amounts that can be charged c X The hospital facility used the Medicare rates when calculating the maximum amounts that can be charged d Other (describe in Section C) 23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? 23 X If "Yes," explain in Section C. 24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? 24 X If "Yes," explain in Section C. Schedule H (Form 990) 2015
JSA
5E1324 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 50 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 7 Part V Facility Information (continued) Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A ("A, 1," "A, 4," "B, 2," "B, 3," etc.) and name of hospital facility.
PART V, SECTION B, LINE 5
IN ERIE COUNTY, KALEIDA HEALTH WORKED WITH THE ERIE COUNTY DEPARTMENT OF
HEALTH, CATHOLIC HEALTH, BUFFALO STATE COLLEGE CENTER FOR HEALTH AND
SOCIAL RESEARCH, P2 COLLABORATIVE OF WESTERN NEW YORK, UNITED WAY OF
BUFFALO & ERIE COUNTY AND UNIVERSITY AT BUFFALO FAMILY MEDICINE.
WHILE THE COUNTY BEGAN THE PROCESS BY DEVELOPING THE SURVEY TOOL AND ITS
DISTRIBUTION METHODS IN THE FALL OF 2012, THE COMMUNITY PARTNERS CAME
TOGETHER IN FEBRUARY 2013. THE SUBSEQUENT MEETINGS IN MARCH, JULY AND
AUGUST OF 2013 SOLIDIFIED THE HEALTH DEPARTMENT, LOCAL HOSPITALS AND
ACADEMIA EFFORTS.
IN ADDITION TO RELYING ON NEW YORK STATE PREVENTION AGENDA DATA, ERIE
COUNTY CONDUCTED A COUNTY-WIDE HEALTH ASSESSMENT WITH A SURVEY AND HELD A
LIVING HEALTHY TASK FORCE TOWN HALL MEETING FOR PROFESSIONAL INPUT.
IN NIAGARA COUNTY, THE NIAGARA COUNTY HEALTH DEPARTMENT, NIAGARA FALLS
MEMORIAL MEDICAL CENTER, MT. ST. MARY'S HOSPITAL, EASTERN NIAGARA
HOSPITAL, NIAGARA COUNTY DEPARTMENT OF MENTAL HEALTH AND UNIVERSITY AT
BUFFALO PREVENTIVE MEDICINE RESIDENCY WITH ASSISTANCE FROM THE P2
COLLABORATIVE OF WESTERN NEW YORK, JOINED TOGETHER FOR THE COMMUNITY
HEALTH EFFORTS. THE NIAGARA COUNTY GROUP LAUNCHED THEIR EFFORTS IN MARCH
2013 AND HELD SUBSEQUENT MEETINGS IN APRIL, MAY, JULY, AUGUST, SEPTEMBER
AND OCTOBER. NIAGARA COUNTY CONDUCTED A COMMUNITY HEALTH SURVEY, WHICH
HAD 1,455 RESPONSES, AND OUTREACH EVENTS INCLUDED HOSTING THREE FOCUS
JSA Schedule H (Form 990) 2015
5E1331 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 51 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 7 Part V Facility Information (continued) Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A ("A, 1," "A, 4," "B, 2," "B, 3," etc.) and name of hospital facility.
GROUPS AND A COUNTY-WIDE COMMUNITY HEALTH MEETING.
IN ADDITION TO THE OUTREACH AND FEEDBACK IN BOTH COUNTIES, KALEIDA HEALTH
ALSO REACHED OUT TO OTHER PARTNERS IN THE COMMUNITY INCLUDING, BUT NOT
LIMITED TO, THE NEAR EAST AND WEST SIDE (NEWS) TASK FORCE, LASTING
EDUCATION FOR WOMEN, ADULTS & CHILDREN (LEWAC) AND GREATER BUFFALO UNITED
ACCOUNTABLE HEALTHCARE NETWORK (GBUAHN).
PART V, SECTION B, LINE 6A
KALEIDA HEALTH IS COMPRISED OF FOUR HOSPITALS - BUFFALO GENERAL MEDICAL
CENTER/GATES VASCULAR INSTITUTE, DEGRAFF MEMORIAL HOSPITAL, MILLARD
FILLMORE SUBURBAN HOSPITAL AND WOMEN & CHILDREN'S HOSPITAL OF BUFFALO.
PART V, SECTION B, LINE 6B
THREE KALEIDA HEALTH HOSPITALS ARE LOCATED IN ERIE COUNTY AND ONE,
DEGRAFF MEMORIAL HOSPITAL, IS LOCATED IN NIAGARA COUNTY LESS THAN ONE
MILE FROM THE ERIE COUNTY BORDER.
IN ERIE COUNTY, KALEIDA HEALTH WORKED WITH CATHOLIC HEALTH THROUGH THE
ERIE COUNTY DEPARTMENT OF HEALTH FOR COMMUNITY COLLABORATION.
IN NIAGARA COUNTY, KALEIDA HEALTH WORKED WITH NIAGARA FALLS MEMORIAL
MEDICAL CENTER, MT. ST. MARY'S HOSPITAL AND EASTERN NIAGARA HOSPITAL
THROUGH THE NIAGARA COUNTY HEALTH DEPARTMENT.
JSA Schedule H (Form 990) 2015
5E1331 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 52 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 7 Part V Facility Information (continued) Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A ("A, 1," "A, 4," "B, 2," "B, 3," etc.) and name of hospital facility.
PART V, SECTION B, LINE 7D
AVAILABLE UPON REQUEST AT THE HOSPITAL FACILITY WITHOUT CHARGE.
PART V, SECTION B, LINE 11
WITH HOSPITALS LOCATED IN BOTH ERIE AND NIAGARA COUNTIES, KALEIDA HEALTH,
WORKING COLLABORATIVELY WITH BOTH COUNTY GROUPS, IDENTIFIED THREE
PROJECTS TO UNDERTAKE AS PART OF THE COMMUNITY SERVICE PLAN. IN ERIE
COUNTY, KALEIDA HEALTH IS WORKING TO INCREASE BREASTFEEDING RATES AND
CARDIOVASCULAR DISEASE SCREENINGS. IN NIAGARA COUNTY, KALEIDA HEALTH IS
ALSO WORKING TO INCREASE CARDIOVASCULAR DISEASE SCREENINGS AND WORK TO
REDUCE THE NUMBER OF FALLS FOR THOSE OVER AGE 65.
THESE THREE AFOREMENTIONED INITIATIVES ARE IN ACCORDANCE WITH THE NEEDS
IDENTIFIED BY THE COMMUNITY AND SUPPORTED THROUGH THE DETAILED ANALYSIS
OUTLINED IN THE 2014-2016 COMMUNITY HEALTH NEEDS ASSESSMENT AND COMMUNITY
SERVICE PLAN.
TWO OTHER TOPICS IDENTIFIED BY THE COMMUNITY AS AREAS OF CONCERN WERE
CANCER AND BEHAVIORAL HEALTH.
ADJACENT TO BUFFALO GENERAL MEDICAL CENTER IS THE ROSWELL PARK CANCER
INSTITUTE, WHICH HOLDS THE NATIONAL CANCER INSTITUTE DESIGNATION AS A
COMPREHENSIVE CANCER CENTER AND HAS A PROVEN MULTIDISCIPLINARY APPROACH.
KALEIDA HEALTH IS COLLABORATING WITH ROSWELL ON THE PROPOSED INTEGRATED
JSA Schedule H (Form 990) 2015
5E1331 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 53 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 7 Part V Facility Information (continued) Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A ("A, 1," "A, 4," "B, 2," "B, 3," etc.) and name of hospital facility.
HEMATOLOGY/ONCOLOGY FLOOR IN THE NEW JOHN R. OISHEI CHILDREN'S HOSPITAL
SET TO OPEN IN 2017. IN RESPONSE TO A COMMUNITY NEED TO ADDRESS THE NEEDS
OF CANCER SURVIVORS, KALEIDA HEALTH ESTABLISHED ITS STAR CERTIFIED
SURVIVOR STEPS PROGRAM IN 2014 THROUGH MILLARD FILLMORE SUBURBAN
HOSPITAL. THE SURVIVOR STEPS PROGRAM IS A SUPPORTIVE CANCER
REHABILITATION AND RECOVERY PROGRAM FOR SURVIVORS OF ANY TYPE OF CANCER
DIAGNOSIS WITH A FOCUS ON IMPROVING INDIVIDUALS PHYSICAL AND EMOTIONAL
FUNCTIONING AS WELL AS THEIR QUALITY OF LIFE. THIS PROGRAM IS UNIQUE IN
THAT IT CAN HELP THOSE THROUGHOUT THEIR BATTLE WITH CANCER FROM DIAGNOSIS
TO REMISSION. STAR IS A NATIONALLY RECOGNIZED CANCER SURVIVORSHIP
CERTIFICATION PROGRAM FOCUSED ON IMPROVING THE LIVES OF SURVIVORS WHO
SUFFER FROM SIDE EFFECTS CAUSED BY TREATMENTS. IN 2015, KALEIDA HEALTH
ACQUIRED CANCER CARE OF WESTERN NEW YORK. THE INTEGRATION OF THIS WELL
ESTABLISHED PRACTICE IS CONSISTENT WITH KALEIDA HEALTH'S OVERALL VISION
OF DELIVERING HIGH-VALUE HEALTH CARE BY BROADENING ITS MARKET PRESENCE IN
ONCOLOGY.
KALEIDA HEALTH'S WOMEN & CHILDREN'S HOSPITAL OF BUFFALO PROVIDES
PEDIATRIC BEHAVIORAL HEALTH SERVICES TO CHILDREN AGES 2 TO 21 THROUGH ITS
CHILDREN'S PSYCHIATRY CLINIC. ADULT BEHAVIORAL HEALTH SCIENCES ARE
PROVIDED AT ERIE COUNTY MEDICAL CENTER, A REGIONAL BEHAVIORAL HEALTH
CENTER OF EXCELLENCE AND THROUGH COMMUNITY-BASED OUTPATIENT SITES.
JSA Schedule H (Form 990) 2015
5E1331 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 54 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 7 Part V Facility Information (continued) Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A ("A, 1," "A, 4," "B, 2," "B, 3," etc.) and name of hospital facility.
PART V, SECTION B, LINE 16I
INFORMATION THAT EXPLAINS HOW QUALIFIED PATIENTS CAN ACCESS FINANCIAL
ASSISTANCE THROUGH THE HOSPITAL IS INCLUDED ON BILLS AND STATEMENTS TO
PATIENTS.
APPLICATION MATERIALS INCLUDE A NOTICE TO THE PATIENTS THAT ONCE THEY
SUBMIT A COMPLETED APPLICATION AND DOCUMENTATION, THEY MAY DISREGARD ANY
BILLS UNTIL THE HOSPITAL HAS RENDERED A WRITTEN DECISION ON THE
APPLICATION. THE HOSPITAL MAY NOT FORWARD ACCOUNTS TO COLLECTION WHILE AN
APPLICATION IS PENDING.
PART V, SECTION B, LINE 18D
UPON VERIFICATION OF EMPLOYMENT WAGES, THE AGENCY WILL GARNISH WAGES ON
KALEIDA HEALTH'S BEHALF.
JSA Schedule H (Form 990) 2015
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How many non-hospital health care facilities did the organization operate during the tax year? 27
Name and address Type of Facility (describe) 1 HIGHPOINTE ON MICHIGAN INPATIENT SKILLED NURSING 1031 MICHIGAN AVE FACILITY BUFFALO NY 14203 2 CENTER FOR LABORATORY MEDICINE HOSPITAL BASED LAB SERVICES 115 FLINT ROAD AMHERST NY 14226 3 MILLARD FILLMORE SURGERY CENTER AMBULATORY SURGERY CENTER 215 KLEIN ROAD WILLIAMSVILLE NY 14221 4 DEGRAFF SKILLED NURSING FACILITY INPATIENT SKILLED NURSING 445 TREMONT STREET FACILITY NORTH TONAWANDA NY 14120 5 ELMWOOD OB/GYN MEDICAL SERVICES - PRIMARY 239 BRYANT STREET CARE, PRENATAL OUTPATIENT BUFFALO NY 14222 6 NORTH BUFFALO MEDICAL PARK MEDICAL SERVICES - PRIMARY 900 HERTEL AVE CARE, RADIOLOGY OUTPATIENT, BUFFALO NY 14207 OUTPATIENT THERAPY SERVICES 7 MAPLE WEST MEDICAL COMPLEX MEDICAL SERVICES - PRIMARY 705 MAPLE ROAD CARE, OTHER SPECIALTIES AMHERST NY 14221 8 COMMUNITY MENTAL HEALTH CENTER HOSPITAL BASED OUTPATIENT 1028 MAIN STREET BEHAVIORAL HEALTH SERVICES BUFFALO NY 14203 9 KALEIDA HEALTH FAMILY PLANNING CENTER OUTPATIENT FAMILY PLANNING 1313 MAIN STREET BUFFALO NY 14209 10 HODGE PEDIATRICS HOSPITAL BASED OUTPATIENT 125 HODGE STREET PRIMARY CARE SERVICES BUFFALO NY 14222 Schedule H (Form 990) 2015
JSA
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How many non-hospital health care facilities did the organization operate during the tax year?
Name and address Type of Facility (describe) 1 WCHOB SPECIALTY CLINICS HOSPITAL BASED OUTPATIENT 140 HODGE STREET PRIMARY CARE SERVICES BUFFALO NY 14222 2 TOWN GARDEN PEDIATRICS HOSPITAL BASED OUTPATIENT 461 WILLIAM STREET PRIMARY CARE SERVICES BUFFALO NY 14204 3 WCHOB WOMEN'S OB/GYN HEALTH CENTER HOSPITAL BASED OUTPATIENT 462 GIRDER STREET PRIMARY CARE SERVICES BUFFALO NY 14215 4 WCHOB MCKINLEY OB/GYN MEDICAL SERVICES - PRIMARY 3860 MCKINLEY PARKWAY CARE BUFFALO NY 14202 5 WCHOB LANCASTER OB/GYN MEDICAL SERVICES - PRIMARY 6363 TRANSIT ROAD CARE, PRENATAL OUTPATIENT LANCASTER NY 14086 6 WCHOB CHILD PROTECTION CENTER MEDICAL SERVICES - PRIMARY 556 FRANKLIN STREET CARE BUFFALO NY 14202 7 STANLEY MAKOWSKI SBHC SCHOOL BASED PRIMARY CARE 1095 JEFFERSON AVE SERVICES BUFFALO NY 14214 8 WCHOB LOCKPORT OB/GYN MEDICAL SERVICES - PRIMARY 475 SOUTH TRANSIT ROAD CARE, PRENATAL OUTPATIENT LOCKPORT NY 14094 9 HILLERY PARK #27 SBHC SCHOOL BASED PRIMARY CARE 72 PAWNEE PARKWAY SERVICES BUFFALO NY 14210 10 BENNETT HIGH SCHOOL SBHC SCHOOL BASED PRIMARY CARE 2885 MAIN STREET SERVICES BUFFALO NY 14214 Schedule H (Form 990) 2015
JSA
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How many non-hospital health care facilities did the organization operate during the tax year?
Name and address Type of Facility (describe) 1 WESTMINSTER #68 SBHC SCHOOL BASED PRIMARY CARE 24 WESTMINSTER AVE SERVICES BUFFALO NY 14215 2 ML KING #39 SBHC SCHOOL BASED PRIMARY CARE 487 HIGH STREET SERVICES BUFFALO NY 14211 3 BUILD ACADEMY #91 SBHC SCHOOL BASED PRIMARY CARE 340 FOUGERON STREET SERVICES BUFFALO NY 14211 4 BUFFALO SCHOOL OF TECHNOLOGY SBHC SCHOOL BASED PRIMARY CARE 414 SOUTH DIVISION STREET SERVICES BUFFALO NY 14201 5 DR. LYDIA WRIGHT #89 SBHC SCHOOL BASED PRIMARY CARE 106 APPENHEIMER STREET SERVICES BUFFALO NY 14214 6 HERMAN BADILLO #76 SBHC SCHOOL BASED PRIMARY CARE 315 CAROLINE STREET SERVICES BUFFALO NY 14201 7 SOUTHTOWNS CLINIC MEDICAL SERVICES - PRIMARY 4535 SOUTHWESTERN BLVD CARE HAMBURG NY 14075 8
9
10
Schedule H (Form 990) 2015
JSA
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Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
PART I, LINE 3C
KALEIDA HEALTH HAS IMPLEMENTED AND COMMUNICATES ITS FINANCIAL ASSISTANCE
(CHARITY CARE) POLICY, WHICH ASSISTS LOW INCOME, UNINSURED OR
UNDERINSURED INDIVIDUALS WHO LACK THE FINANCIAL RESOURCES TO PAY FOR
MEDICAL SERVICES RENDERED. LEVELS OF DISCOUNTS ARE AWARDED BASED UPON
INCOME AND ASSET VERIFICATION AND IN ACCORDANCE WITH THE FEDERAL POVERTY
GUIDELINES AS PUBLISHED ANNUALLY BY THE U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES. INDIVIDUALS ARE PROVIDED FINANCIAL ASSISTANCE CONTACT
INFORMATION DURING INTAKE AND REGISTRATION.
THE APPLICANT FOR FREE OR REDUCED PRICE CARE WORKS DIRECTLY WITH A MEMBER
OF THE FINANCIAL COUNSELING OR CHARITY CARE TEAM FOR FINANCIAL SCREENING
AND ENROLLMENT IN A GOVERNMENT-FUNDED PROGRAM, IF ELIGIBLE.
AFTER REVIEW OF INCOME AND ASSETS, AN INDIVIDUAL MAY BE APPROVED FOR FREE
CARE (100% DISCOUNT) OR A DISCOUNT LEVEL OF 50, 60, 75, OR 90%, FOR
MEDICALLY NECESSARY SERVICES RENDERED AT A KALEIDA FACILITY, AS FOLLOWS:
JSA Schedule H (Form 990) 2015
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Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
LESS THAN 200% OF FEDERAL POVERTY GUIDELINE IS AWARDED 100% DISCOUNT
200% - 249% OF FEDERAL POVERTY GUIDELINE IS AWARDED 90% DISCOUNT
250% - 299% OF FEDERAL POVERTY GUIDELINE IS AWARDED 75% DISCOUNT
300% - 349% OF FEDERAL POVERTY GUIDELINE IS AWARDED 60% DISCOUNT
350% - 400% OF FEDERAL POVERTY GUIDELINE IS AWARDED 50% DISCOUNT
PART I, LINE 7
THE AMOUNTS REPORTED IN THE TABLE UNDER PART 1, LINE 7 WERE DETERMINED
USING THE HEALTH SYSTEM'S DECISION SUPPORT SOFTWARE PROGRAM AND REVENUE
AND EXPENSES FROM THE GENERAL LEDGER. THE OVERALL REVENUE AND EXPENSES
INCLUDED IN THE DECISION SUPPORT SOFTWARE PROGRAM WERE RECONCILED TO THE
GENERAL LEDGER WHICH RECONCILES TO THE AUDITED FINANCIAL STATEMENTS. THE
DECISION SUPPORT SOFTWARE PROGRAM ALLOCATES DIRECT COSTS TO EACH PATIENT
ACCOUNT BASED ON THE RESOURCES USED BY THAT PATIENT WITHIN THE SPECIFIC
COST CENTER. INDIRECT COSTS ARE ALLOCATED USING SIMILAR STEPDOWN
METHODOLOGY USED BY CMS IN THE INSTITUTIONAL COST REPORT.
JSA Schedule H (Form 990) 2015
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Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
PART II
COMMUNITY BUILDING ACTIVITIES
KALEIDA HEALTH'S COMMUNITY BUILDING ACTIVITIES SERVE THE WESTERN NEW YORK
REGION BY FACILITATING, DEVELOPING, COORDINATING, AND COMMUNICATING A
MYRIAD OF COMMUNITY HEALTH EDUCATION PROGRAMS, OUTREACH SERVICES,
SPEAKERS, AND COMMUNITY REFERRALS. PROGRAMS ARE TARGETED FOR PEOPLE OF
ALL AGES FROM SCHOOL-AGED CHILDREN TO SENIOR CITIZENS AND PROMOTE THE
REDUCTION OF HEALTH DISPARITIES, EFFECTIVE USE OF HEALTH SERVICES, AND
PROMOTE OVERALL COMMUNITY HEALTH AND WELLNESS. TOPICS RANGE FROM HEALTH
INSURANCE ENROLLMENT TO DIABETES, STROKE, AND HEART DISEASE, BLOOD
PRESSURE SCREENING, MATERNAL AND CHILD HEALTH TO DISCUSSIONS ABOUT
CAREERS IN HEALTHCARE.
PART III, LINES 2 AND 3
BAD DEBT EXPENSE IS RECORDED USING THE VALUATION METHOD AS OUTLINED IN
HEALTHCARE FINANCIAL MANAGEMENT ASSOCIATION STATEMENT 15, WHICH REQUIRES
BAD DEBT EXPENSE TO BE RECORDED AT THE AMOUNT THAT THE PAYER IS EXPECTED
TO PAY. IN ORDER TO REPORT THE COSTS ASSOCIATED WITH BAD DEBT EXPENSE,
JSA Schedule H (Form 990) 2015
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Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
THE REPORTED BAD DEBT EXPENSE NEEDS TO BE ADJUSTED SO THAT THE AMOUNT
EXPECTED TO BE PAID REFLECTS GROSS CHARGES, PRIOR TO THE APPLICATION OF
AN RCC. KALEIDA HEALTH ADJUSTS BAD DEBT EXPENSE PRIOR TO THE APPLICATION
OF AN RCC SO THAT THE REPORTED BAD DEBT EXPENSE AT COST, ON PART III,
LINE 2 OF IRS FORM 990, SCHEDULE H REFLECTS THE TRUE COST OF THE BAD
DEBTS. THE ORGANIZATION HAS A CHARITY CARE POLICY, AND ANY WRITE-OFFS AS
A RESULT OF THIS POLICY ARE RECORDED AS CHARITY CARE ALLOWANCES AND ARE A
REDUCTION OF THE NET PATIENT REVENUE. INDIVIDUALS WHO MAY QUALIFY FOR
CHARITY CARE ASSISTANCE UNDER THE POLICY, BUT DO NOT VOLUNTEER TO
COMPLETE THE APPLICATION PROCESS WOULD NOT BE GRANTED CHARITY CARE
ASSISTANCE. KALEIDA USES A PRESUMPTIVE CHARITY CARE PROCESS, WHICH HAS
DETERMINED THAT 27% OF SELF-PAY BAD DEBT EXPENSE IN 2015 WOULD HAVE BEEN
ELIGIBLE FOR CHARITY CARE ASSISTANCE.THEREFORE, WE BELIEVE THAT THE LEVEL
OF CHARITY CARE INCLUDED IN BAD DEBT EXPENSE TO BE APPROXIMATELY
$541,145. WE ESTIMATED THIS AMOUNT BY USING THE 2015 CALCULATED
PRESUMPTIVE ELIGIBILITY PERCENTAGE ON BAD DEBT WRITE-OFF AMOUNTS OVER
$500 (24.5%), TO DETERMINE THE BAD DEBT WRITE-OFFS THAT WOULD BE
ELIGIBLE, IF THEY WERE SCORED USING THE PRESUMPTIVE ELIGIBILITY PROCESS.
JSA Schedule H (Form 990) 2015
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Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
BAD DEBT IS NOT INCLUDED AS A COMMUNITY BENEFIT.
PART III, LINE 4
KALEIDA PROVIDES CARE TO PATIENTS WHO MEET CERTAIN CRITERIA UNDER ITS
CHARITY CARE POLICIES WITHOUT CHARGE OR AT AMOUNTS LESS THAN THEIR
ESTABLISHED RATES. BECAUSE KALEIDA DOES NOT ANTICIPATE COLLECTIONS OF
AMOUNTS DETERMINED TO QUALIFY AS CHARITY CARE, THEY ARE NOT REPORTED AS
REVENUE.
KALEIDA GRANTS CREDIT WITHOUT COLLATERAL TO PATIENTS, MOST OF WHOM ARE
LOCAL RESIDENTS AND ARE INSURED BY COMMERCIAL AND GOVERNMENT INSURANCE
PLANS. ADDITIONS TO THE ESTIMATED ALLOWANCE FOR DOUBTFUL ACCOUNTS ARE
MADE BY MEANS OF THE PROVISION OF BAD DEBTS. ACCOUNTS WRITTEN OFF AS
UNCOLLECTIBLE ARE DEDUCTED FROM THE ALLOWANCE AND SUBSEQUENT RECOVERIES
ARE ADDED. THE AMOUNT OF THE PROVISION FOR BAD DEBTS IS BASED UPON
MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS,
BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN FEDERAL AND STATE
GOVERNMENTAL HEALTHCARE COVERAGE AND OTHER COLLECTION INDICATORS. THE
JSA Schedule H (Form 990) 2015
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Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
PROVISION FOR BAD DEBTS PRIMARILY RELATES TO PATIENTS WITHOUT INSURANCE
AND TO THOSE THAT ARE EITHER UNDERINSURED OR WITHOUT THE NECESSARY
RESOURCES TO PAY CONISURANCE AND DEDUCTIBLE BALANCES.
PART III, LINE 8
THERE ARE NO MEDICARE SHORTFALLS INCLUDED IN THE CALCULATION OF COMMUNITY
BENEFIT.
COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS
REPORTED IN THE MEDICARE COST REPORT, AS REFLECTED IN PART III, LINE 6:
KALEIDA HEALTH USED THE FILED, BUT UNAUDITED 2015 CMS MEDICARE COST
REPORT TO DETERMINE THE AMOUNTS REPORTED ON THESE LINES.
PART III, LINE 9B - BAD DEBT, MEDICARE & COLLECTION PRACTICES
ONCE PATIENT LIABILITY HAS BEEN DETERMINED FOLLOWING PROCESSING OF
APPLICATIONS FOR GOVERNMENT ASSISTANCE, CHARITY CARE, AND/OR INSURANCE
CARRIER REMITTANCE, THE PATIENT STATEMENT IS MAILED FOR PAYMENT RECOVERY.
KALEIDA HEALTH HAS A PRE-COLLECTION PROCESS FOR ACCOUNTS WITH A POSITIVE
JSA Schedule H (Form 990) 2015
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Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
PATIENT BALANCE GREATER THAN $4.99, AND A FIRST BILL DATE OLDER THAN 60
DAYS BUT NOT PREVIOUSLY PAID IN FULL BY THE PATIENT (EXCLUDING ACCOUNTS
FOR PATIENTS THAT HAVE SUBMITTED A COMPLETED APPLICATION FOR CHARITY
CARE, MEDICAID, OR CHILD HEALTH PLUS, AND AN ELIGIBILITY DETERMINATION IS
PENDING).
UPON A PATIENT EXPRESSING FINANCIAL CONCERN, THE PATIENT WILL BE OFFERED
THE OPPORTUNITY TO APPLY FOR FINANCIAL ASSISTANCE (CHARITY CARE). ONCE
THE PATIENT SUBMITS THE COMPLETED APPLICATION, THE ACCOUNT IS PLACED ON
HOLD AND ALL COLLECTION ACTIVITIES ARE SUSPENDED UNTIL AN ELIGIBILITY
DETERMINATION IS MADE. IF THE PATIENT IS ELIGIBLE FOR CHARITY CARE, THEN
THE PATIENT IS NOTIFIED OF THE LEVEL OF CHARITY CARE AWARDED. IF 100%
CHARITY CARE IS AWARDED, THEN NO BILL IS SENT TO THE PATIENT. IF LESS
THAN 100% CHARITY CARE IS AWARDED, THEN THE PATIENT WILL RECEIVE A BILL
PURSUANT TO THE PRIVATE PAY COLLECTION POLICY.
COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS
KALEIDA HEALTH ASSESSES THE NEEDS OF THE COMMUNITY THROUGH A COMMUNITY
JSA Schedule H (Form 990) 2015
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Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
HEALTH NEEDS ASSESSMENT. THE CHNA WAS COMPLETED IN 2013. A COPY OF THE
CHNA CAN BE FOUND ON OUR WEBSITE AT
WWW.KALEIDAHEALTH.ORG/COMMUNITY/PUBLICATIONS.ASP.
PATIENT EDUCATION OF ELIGIBILITY FOR ASSISTANCE
KALEIDA HEALTH INFORMS INDIVIDUALS OF FINANCIAL ASSISTANCE MADE AVAILABLE
AT THE TIME OF REGISTRATION INTO THE INPATIENT, OUTPATIENT, EMERGENCY
DEPARTMENT AND LONG-TERM CARE FACILITY. POSTERS INFORMING THE
PATIENT/FAMILY OF ASSISTANCE ARE AVAILABLE THROUGHOUT THE KALEIDA
LOCATIONS. BROCHURES AND PAMPHLETS INFORMING THE COMMUNITY ARE WIDELY
DISTRIBUTED IN THE COMMUNITY AT HEALTH FAIRS, CHURCHES, SCHOOLS AND OTHER
PUBLIC LOCATIONS. INFORMATION REGARDING THE AVAILABILITY OF FINANCIAL
ASSISTANCE AS WELL AS APPLICATION IS ALSO MADE AVAILABLE THROUGH KALEIDA
HEALTH'S WEBSITE.
KALEIDA HEALTH OFFERS ASSISTANCE TO INDIVIDUALS IN OUR COMMUNITY FOR
ACCESSING AFFORDABLE HEALTH CARE, INCLUDING:
JSA Schedule H (Form 990) 2015
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Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
*NYS HEALTH MARKETPLACE: ASSISTS WITH NAVIGATING, EDUCATING AND
ENROLLMENT IN THE NYS HEALTH MARKETPLACE OFFERINGS. DEDICATED AND
STATE-TRAINED STAFF IS AVAILABLE TO ASSIST INDIVIDUALS IN PERSON OR VIA
THE PHONE. KALEIDA HEALTH OFFERS IN-PERSON APPOINTMENTS AT (5) FIVE
DIFFERENT SITE LOCATIONS.
*FACILITATED ENROLLMENT: ASSISTS ELIGIBLE INDIVIDUALS WITH HEALTH
INSURANCE ENROLLMENT BY OFFERING EDUCATION AND APPLICATION ASSISTANCE FOR
MEDICAID, CHILD HEALTH PLUS, ESSENTIAL PLANS, STATE AID PROGRAM FOR
CHILDREN WITH SPECIAL NEEDS AND ALL QUALIFIED HEALTH PLANS MADE AVAILABLE
THROUGH THE AFFORDABLE CARE ACT. A DEDICATED TELEPHONE NUMBER IS
AVAILABLE AND INFORMATION IS PUBLISHED IN BROCHURES AT KALEIDA SITES AND
AT VARIOUS LOCATIONS THROUGHOUT THE COMMUNITY.
*FINANCIAL ASSISTANCE PROGRAM: AS DESCRIBED ABOVE, THE KALEIDA FINANCIAL
ASSISTANCE PROGRAM, IF ELIGIBLE, PROVIDES FREE OR REDUCED-PRICES FOR
PATIENTS TREATED AT KALEIDA HEALTH HOSPITALS OR LONG-TERM CARE
FACILITIES. DISCOUNTS ARE AWARDED BASED UPON INCOME AND ASSET
JSA Schedule H (Form 990) 2015
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Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
VERIFICATION.
*PRESUMPTIVE ELIGIBILITY: KALEIDA HEALTH HAS SHOWN A WILLINGNESS TO
EXTEND FINANCIAL ASSISTANCE TO NEEDY PATIENTS WITH OUTSTANDING BILLS WHO
HAVE NOT COMPLETED THE CHARITY APPLICATION PROCESS.
COMMUNITY INFORMATION
THREE KALEIDA HEALTH HOSPITALS ARE LOCATED IN ERIE COUNTY AND ONE,
DEGRAFF MEMORIAL HOSPITAL, IS LOCATED IN NIAGARA COUNTY LESS THAN ONE
MILE FROM THE ERIE COUNTY BORDER.
ERIE COUNTY
ACCORDING TO MEDSTAT MARKET EXPERT 2013 DATA, LESS THAN ONE MILLION
PEOPLE RESIDE IN ERIE COUNTY. THE POPULATION CONTINUES TO DECLINE AND
HAS DONE SO EVEN SINCE THE 2010 CENSUS WHERE THERE WERE 925,717 RESIDENTS
IN COMPARISON TO THE 922,988 WHO LIVE IN THE COUNTY TODAY. SIMILAR TO
NEW YORK STATE, THERE ARE MORE FEMALES THAN MALES. HOWEVER, THERE ARE
FEWER CHILDREN UNDER AGE 18 AND MORE RESIDENTS OVER AGE 55 IN COMPARISON
JSA Schedule H (Form 990) 2015
5E1327 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 68 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 9 Part VI Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
TO NEW YORK AND THE UNITED STATES. ERIE COUNTY RESIDENTS ALSO HAVE A
LOWER HOUSEHOLD INCOME THAN THE NEW YORK STATE AVERAGE, WHICH IS EVIDENT
IN A HIGHER PERCENTAGE OF RESIDENTS EARNING LESS THAN $25,000 PER YEAR
AND FEWER EARNING OVER $100,000. IN ADDITION, 67 CENSUS TRACKS ARE
IDENTIFIED AS MEDICALLY UNDERSERVED AREAS/POPULATIONS.
THE LARGEST MUNICIPALITY IN ERIE COUNTY IS THE CITY OF BUFFALO WITH
277,681 RESIDENTS. THE AVERAGE HOUSEHOLD INCOME IN THE CITY OF BUFFALO,
$44,979, IS SIGNIFICANTLY LESS THAN THE STATE AVERAGE. OVER 42 PERCENT
OF HOUSEHOLDS EARN LESS THAN $25,000 PER YEAR INCLUDING 26.8 PERCENT
EARNING LESS THAN $15,000 AND ONLY 8.4 PERCENT EARNING OVER $100,000. A
DIRECT CORRELATION CAN BE DRAWN TO INCOME FROM THE FACT THAT OVER 17
PERCENT OF RESIDENTS OVER AGE 25 DO NOT HAVE A HIGH SCHOOL DEGREE. THE
POPULATION IN THE CITY OF BUFFALO ALSO HAS A HIGHER PERCENTAGE OF BLACK
NON-HISPANICS AND HISPANICS AS COMPARED TO THE REST OF THE COUNTY, 35.6
PERCENT TO 13 PERCENT RESPECTIVELY.
NIAGARA COUNTY
JSA Schedule H (Form 990) 2015
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Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
ACCORDING TO THE MEDSTAT MARKET EXPERT 2013 DATA, JUST OVER 215,000
PEOPLE RESIDE IN NIAGARA COUNTY. LIKE OTHER UPSTATE NEW YORK
MUNICIPALITIES, THE POPULATION CONTINUES TO DECLINE AND HAS DONE SO EVEN
SINCE THE 2010 CENSUS WHERE THERE WERE 216,149 RESIDENTS. ALSO SIMILAR
TO NEIGHBORING COUNTIES, THERE ARE MORE FEMALES THAN MALES, A LOW
PERCENTAGE OF CHILDREN UNDER AGE 18 AND A HIGH PERCENTAGE OF RESIDENTS
OVER AGE 55. NIAGARA COUNTY RESIDENTS ALSO HAVE A LOWER HOUSEHOLD INCOME
THAN THE NEW YORK STATE AND NATIONAL AVERAGES. HERE, 21 CENSUS TRACKS
ARE IDENTIFIED AS MEDICALLY UNDERSERVED AREAS/POPULATIONS.
THE CITY OF NIAGARA FALLS IS THE LARGEST MUNICIPALITY IN NIAGARA COUNTY.
RESIDENTS IN NIAGARA FALLS HAVE AN AVERAGE SALARY EQUIVALENT TO THE CITY
OF BUFFALO. LIKE MOST INNER CITIES IN COMPARISON TO THE SUBURBS, THERE
ARE A HIGH PERCENTAGE OF HOUSEHOLDS, HERE CLOSE TO 40 PERCENT, THAT EARN
LESS THAN $25,000. AS COMPARED TO NORTH TONAWANDA AND THE COUNTY, THERE
ARE FEWER WHITE NON-HISPANICS, FEWER RESIDENTS OVER AGE 25 WITH A
BACHELOR'S DEGREE OR HIGHER AND A HIGHER PERCENTAGE OF RESIDENTS THAT DO
NOT HAVE A HIGH SCHOOL DEGREE. NORTH TONAWANDA, WHERE DEGRAFF IS
JSA Schedule H (Form 990) 2015
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Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
PHYSICALLY LOCATED ON THE ERIE COUNTY BORDER, HAS A HIGH PERCENTAGE OF
WHITE NON-HISPANICS AND ONLY ONE PERCENT OF NON-HISPANIC BLACKS.
RESIDENTS IN NORTH TONAWANDA ALSO HAVE A HIGHER AVERAGE HOUSEHOLD INCOME
IN COMPARISON TO THE REST OF THE COUNTY AS MORE RESIDENTS HAVE A
BACHELOR'S DEGREE AND EARN OVER $100,000. HOWEVER, THE AVERAGE INCOME IS
STILL LESS THAN THE NEW YORK STATE AND U.S. AVERAGES.
THERE ARE SIX OTHER HOSPITALS IN ERIE COUNTY AND FOUR OTHER HOSPITALS IN
NIAGARA COUNTY SERVING THE COMMUNITIES.
MORE INFORMATION CAN BE FOUND IN THE 2014-2016 COMMUNITY HEALTH NEEDS
ASSESSMENT AND COMMUNITY SERVICE PLAN. THE CHNA WAS COMPLETED IN FALL
2013. A COPY OF THE CHNA CAN BE FOUND ON OUT WEBSITE AT
WWW.KALEIDAHEALTH.ORG/COMMUNITY/PUBLICATIONS.ASP.
PROMOTION OF COMMUNITY HEALTH
KALEIDA HEALTH'S MISSION IS TO ADVANCE THE HEALTH OF THE COMMUNITY.
KALEIDA HEALTH'S VISION IS TO PROVIDE COMPASSIONATE, HIGH-VALUE, QUALITY
JSA Schedule H (Form 990) 2015
5E1327 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 71 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 9 Part VI Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
CARE, IMPROVING HEALTH IN WESTERN NEW YORK AND BEYOND, EDUCATING FUTURE
HEALTH CARE LEADERS AND DISCOVERING INNOVATIVE WAYS TO ADVANCE MEDICINE.
KALEIDA HEALTH'S VALUES CLEARLY STATE WHO THEY ARE AND HOW THEY PERFORM
THEIR WORK:
C - REMAIN CENTERED AROUND THE PATIENT AND FAMILY.
A - BE ACCOUNTABLE TO PATIENTS AND EACH OTHER.
R - SHOW RESPECT AND INTEGRITY.
E - PROVIDE EXCELLENCE IN ALL WE DO.
TO CARRY OUT THE MISSION, MUCH OF KALEIDA HEALTH'S COMMUNITY BENEFIT WORK
IS FOCUSED ON THE NEEDS OF LOW INCOME, MEDICALLY UNDERSERVED POPULATIONS.
KALEIDA HEALTH REPRESENTATIVES ACTIVELY ENGAGE IN VARIOUS COMMUNITY
HEALTH COLLABORATIONS WITH LOCAL HEALTH DEPARTMENTS, STATE HEALTH
DEPARTMENT AND LOCAL NOT-FOR-PROFIT HEALTH AND HUMAN SERVICE AGENCIES.
POVERTY TRENDS, COMMUNITY HEALTH RESEARCH AND LOCAL COMMUNITY HEALTH
NEEDS ARE REVIEWED ON A REGULAR BASIS WHILE PLANNING SERVICES AND
JSA Schedule H (Form 990) 2015
5E1327 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 72 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 9 Part VI Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
PROGRAMS. RESPONSIVE TO COMMUNITY PRIORITIES, PROGRAM DEVELOPMENT AND
SERVICES FILL IDENTIFIED GAPS OR SUPPLEMENT EXISTING PROGRAMS.
MOST KALEIDA HEALTH COMMUNITY HEALTH OUTREACH PROGRAMS ARE OFFERED IN
PARTNERSHIP WITH OTHER COMMUNITY ORGANIZATIONS OR GOVERNMENT AGENCIES IN
ORDER TO LEVERAGE RESOURCES AND MEET THE COMMUNITY'S NEEDS. THIS
INCLUDES EDUCATION AND ACTIVE PARTICIPATION IN HEALTH EVENTS WITH
TARGETED AUDIENCES. INFORMATION REGARDING AVAILABILITY OF COMMUNITY
HEALTH PROGRAMS, ASSISTANCE WITH HEALTH INSURANCE ENROLLMENT AND
FINANCIAL ASSISTANCE FOR MEDICAL CARE RECEIVED AT KALEIDA HEALTH
HOSPITALS, EMERGENCY DEPARTMENTS, OUTPATIENT CLINICS, OR LONG-TERM CARE
FACILITIES IS DISSEMINATED TO THE PUBLIC IN THE COMMUNITY BENEFIT AND
TREINNIAL COMMUNITY SERVICES PLAN AND AVAILABLE ON THE KALEIDA HEALTH
WEBSITE OR IN PRINT FORM UPON REQUEST.
THE VISITING NURSING ASSOCIATION OF WESTERN NEW YORK, INC., KALEIDA
HEALTH'S HOME CARE AFFILIATE, ALSO WORKS TO PROMOTE THE HEALTH OF THE
COMMUNITY. THIS INCLUDES EDUCATING CHRONIC CARE PATIENTS ON
JSA Schedule H (Form 990) 2015
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Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
SELF-MANAGEMENT AND PERSONAL CARE IN AREAS SUCH AS REHABILITATION
SERVICES, NUTRITION EDUCATION AND THERAPY, INFECTION CONTROL, FALLS RISK
ASSESSMENT AND INTERVENTION, AND HEALTH EDUCATION RELATED TO IMPROVED
LIFESTYLE CHOICES FOR INDIVIDUALS AND FAMILIES IN THEIR HOMES AND THE
COMMUNITY. COMMUNITY-BASED PREVENTION PROGRAMS, SUCH AS ONE OF THE
AREA'S LARGEST ANNUAL COMMUNITY INFLUENZA IMMUNIZATION PROGRAM, ALSO ARE
OFFERED THROUGH THE VISITING NURSING ASSOCIATION.
AFFILIATED HEALTH CARE SYSTEM
KALEIDA HEALTH IS A PART OF AN AFFILIATED HEALTH CARE SYSTEM WHOSE
MEMBERS INCLUDE: KALEIDA HEALTH FOUNDATION, VISITING NURSING ASSOCIATION
OF WESTERN NY, INC., VNA HOMECARE SERVICES, INC., AND THE WOMEN AND
CHILDREN'S HOSPITAL OF BUFFALO FOUNDATION.
THE MEMBERS OF THIS SYSTEM, INCLUDING KALEIDA HEALTH, HAVE A MISSION TO
PROVIDE HEALTH CARE AND HEALTH CARE RELATED SERVICES TO THE COMMUNITY.
THE ROLES OF KALEIDA HEALTH'S AFFILIATES IN THIS MISSION ARE DESCRIBED
BELOW.
JSA Schedule H (Form 990) 2015
5E1327 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 74 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 9 Part VI Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
KALEIDA HEALTH FOUNDATION SOLICITS, MAINTAINS, AND ENHANCES THE VALUE OF
PUBLIC CONTRIBUTIONS AND PROVIDES FINANCIAL SUPPORT TO KALEIDA HEALTH IN
ITS MISSION TO ADVANCE COMMUNITY HEALTH.
THE VISITING NURSING ASSOCIATION OF WESTERN NY AND VNA HOMECARE SERVICES
PROMOTE COMMUNITY HEALTH THROUGH THE PROVISION OF HOME CARE AND HOME CARE
RELATED SERVICES.
THE WOMEN AND CHILDREN'S HOSPITAL OF BUFFALO FOUNDATION SOLICITS,
MAINTAINS, AND ENHANCES THE VALUE OF PUBLIC CONTRIBUTIONS TO PROVIDE
FINANCIAL SUPPORT TO THE WOMEN AND CHILDREN'S HOSPITAL OF BUFFALO IN ITS
MISSION TO PROVIDE PEDIATRIC AND WOMEN'S HEALTHCARE SERVICES IN THE
COMMUNITY.
KALEIDA HEALTH BOARD OF DIRECTORS
KALEIDA HEALTH MAINTAINS CONTROL OVER THE CORPORATION THROUGH ITS
SELF-PERPETUATING, 14 MEMBER GOVERNING BOARD OF DIRECTORS. THE BOARD OF
JSA Schedule H (Form 990) 2015
5E1327 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 75 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 9 Part VI Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
DIRECTORS, THE MAJORITY OF WHOM RESIDE IN WESTERN NEW YORK, IS COMPRISED
OF COMMUNITY LEADERS FROM THE BUSINESS, INDUSTRY, AND HEALTHCARE SECTORS,
INCLUDING PHYSICIANS WHO ARE ON THE MEDICAL STAFF. EACH DIRECTOR SERVES
A THREE-YEAR TERM.
STATE FILING OF COMMUNITY BENEFIT REPORT
NEW YORK
JSA Schedule H (Form 990) 2015
5E1327 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 76 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 9 Part VI Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
ATTACHMENT 1
990 SCHEDULE H, PART IV (E) PHYSICIANS PROFIT % OR (A) NAME OF ENTITY (B) DESCRIPTION OF PRIMARY (C) ORG. PROFIT (D) EMPLOYEES STOCK ACTIVITY OF ENTITY % OR STOCK PROFIT % OR OWNERSHIP % OWNERSHIP % STOCK OWNERSHIP %
HARLEM IMAGING, LLC IMAGING SERVICES 50.00000 SOUTHTOWNS SURG CTR PHYSICIAN SERVICES 57.25000 42.75000
JSA Schedule H (Form 990) 2015
5E1327 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 77 KALEIDA HEALTH 16-1533232 Schedule H (Form 990) 2015 Page 9 Part VI Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b. 2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B. 3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization's financial assistance policy. 4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves. 5 Promotion of community health. Provide any other information important to describing how the organization's hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.). 6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served. 7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
STATE FILING OF COMMUNITY BENEFIT REPORT
NY,
JSA Schedule H (Form 990) 2015
5E1327 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 78 SCHEDULE I Grants and Other Assistance to Organizations, OMB No. 1545-0047 (Form 990) Governments, and Individuals in the United States Complete if the organization answered "Yes" on Form 990, Part IV, line 21 or 22. Attach to Form 990. Open to Public Department of the Treasury Internal Revenue Service Information about Schedule I (Form 990) and its instructions is at www.irs.gov/form990. Inspection Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 Part I General Information on Grants and Assistance 1 Does the organization maintain records to substantiate the amount of the grants or assistance, the grantees' eligibility for the grants or assistance, and the selection criteria used to award the grants or assistance? X Yes No 2 Describe in Part IV the organization's procedures for monitoring the use of grant funds in the United States. Part II Grants and Other Assistance to Domestic Organizations and Domestic Governments. Complete if the organization answered “Yes” on Form 990, Part IV, line 21, for any recipient that received more than $5,000. Part II can be duplicated if additional space is needed.
(c) IRC section (d) Amount of cash (e) Amount of non- (f) Method of valuation (g) Description of (h) Purpose of grant 1 (a) Name and address of organization (b) EIN (book, FMV, appraisal, or government if applicable grant cash assistance other) non-cash assistance or assistance
(1) UNIVERSITY ORTHOPEDIC SERVICE 5500 MAIN STREET BUFFALO, NY 14221 16-1406947 N/A 120,000. CONTRIBUTION (2) UB FOUNDATION 3435 MAIN STREET BUFFALO, NY 14231 16-0865182 501(C)(3) 32,000. SPONSORSHIP (3) SAVING GRACE MINISTRIES PO BOX 1013 WILLIAMSVILLE, NY 14231 16-1573408 N/A 20,000. SPONSORSHIP (4) MARCH OF DIMES FOUNDATION 1275 MAMARONECK AVE WHITE PLAINS, NY 10605 13-1846366 501(C)(3) 7,700. SPONSORSHIP (5) SUSAN G. KOMEN FOR THE CURE ELM & CARLTON STREETS BUFFALO, NY 14263 75-1835298 501(C)(3) 6,000. SPONSORSHIP (6) CHAMBER OF COMMERCE OF THE TONAWANDAS, INC. 15 WEBSTER STREET NORTH TONAWANDA, NY 14120 16-0371125 501(C)(3) 5,600. SPONSORSHIP (7)
(8)
(9)
(10)
(11)
(12) 2 Enter total number of section 501(c)(3) and government organizations listed in the line 1 table 4. 3 Enter total number of other organizations listed in the line 1 table 2. For Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule I (Form 990) (2015)
JSA 5E1288 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 79 KALEIDA HEALTH 16-1533232 Schedule I (Form 990) (2015) Page 2 Part III Grants and Other Assistance to Individuals in the United States. Complete if the organization answered "Yes" on Form 990, Part IV, line 22. Part III can be duplicated if additional space is needed.
(a) Type of grant or assistance (b) Number of (c) Amount of (d) Amount of (e) Method of valuation (book, (f) Description of non-cash assistance recipients cash grant non-cash assistance FMV, appraisal, other)
1
2
3
4
5
6
7 Part IV Supplemental Information. Complete this part to provide the information required in Part I, line 2, Part III, column (b), and any other additional information. FORM 990, SCHEDULE I:
DESCRIPTION OF ORGANIZATION'S PROCEDURES FOR MONITORING THE USE OF
GRANTS:
KALEIDA HEALTH MAKES CONTRIBUTIONS TO ORGANIZATONS IN WESTERN NEW YORK
THAT ALSO HAVE HEALTH CARE RELATED ACTIVITIES. ALL CONTRIBUTIONS MUST BE
APPROVED BY THE GOVERNING BODY BEFORE MONEY IS DISTRIBUTED.
Schedule I (Form 990) (2015)
JSA
5E1504 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 80 SCHEDULE J Compensation Information OMB No. 1545-0047 (Form 990) For certain Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees Complete if the organization answered "Yes" on Form 990, Part IV, line 23. Open to Public Department of the Treasury Attach to Form 990. Internal Revenue Service Information about Schedule J (Form 990) and its instructions is at www.irs.gov/form990. Inspection Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 Part I Questions Regarding Compensation Yes No 1a Check the appropriate box(es) if the organization provided any of the following to or for a person listed on Form 990, Part VII, Section A, line 1a. Complete Part III to provide any relevant information regarding these items. First-class or charter travel Housing allowance or residence for personal use Travel for companions Payments for business use of personal residence Tax indemnification and gross-up payments X Health or social club dues or initiation fees Discretionary spending account Personal services (e.g., maid, chauffeur, chef)
b If any of the boxes on line 1a are checked, did the organization follow a written policy regarding payment or reimbursement or provision of all of the expenses described above? If "No," complete Part III to explain 1b X 2 Did the organization require substantiation prior to reimbursing or allowing expenses incurred by all directors, trustees, and officers, including the CEO/Executive Director, regarding the items checked in line 1a? 2 X 3 Indicate which, if any, of the following the filing organization used to establish the compensation of the organization's CEO/Executive Director. Check all that apply. Do not check any boxes for methods used by a related organization to establish compensation of the CEO/Executive Director, but explain in Part III. XXCompensation committee Written employment contract XXIndependent compensation consultant Compensation survey or study XXForm 990 of other organizations Approval by the board or compensation committee 4 During the year, did any person listed on Form 990, Part VII, Section A, line 1a, with respect to the filing organization or a related organization: a Receive a severance payment or change-of-control payment? 4a X b Participate in, or receive payment from, a supplemental nonqualified retirement plan? 4b X c Participate in, or receive payment from, an equity-based compensation arrangement? 4c X If "Yes" to any of lines 4a-c, list the persons and provide the applicable amounts for each item in Part III.
Only section 501(c)(3), 501(c)(4), and 501(c)(29) organizations must complete lines 5–9. 5 For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any compensation contingent on the revenues of: a The organization? 5a X b Any related organization? 5b X If "Yes" to line 5a or 5b, describe in Part III. 6 For persons listed on Form 990, Part VII, Section A, line 1a, did the organization pay or accrue any compensation contingent on the net earnings of: a The organization? 6a X b Any related organization? 6b X If "Yes" on line 6a or 6b, describe in Part III. 7 For persons listed on Form 990, Part VII, Section A, line 1a, did the organization provide any non-fixed payments not described on lines 5 and 6? If "Yes," describe in Part III 7 X 8 Were any amounts reported on Form 990, Part VII, paid or accrued pursuant to a contract that was subject to the initial contract exception described in Regulations section 53.4958-4(a)(3)? If "Yes," describe in Part III 8 X 9 If "Yes" to line 8, did the organization also follow the rebuttable presumption procedure described in Regulations section 53.4958-6(c)? 9 For Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule J (Form 990) 2015
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Schedule J (Form 990) 2015 Page 2 Part II Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed. For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII. Note: The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and (D) Nontaxable (E) Total of columns (F) Compensation other deferred benefits (B)(i)-(D) in column (B) reported (A) Name and Title (i) Base (ii) Bonus & incentive (iii) Other compensation compensation compensation reportable as deferred on prior Form 990 compensation
JAMES KASKIE(i) 0. 0. 1,109,433. 0. 0. 1,109,433. 0. 1FORMER CEO EX-OFFICIO W/ VOTE (ii) 0. 0. 0. 0. 0. 0. 0. JODY LOMEO(i) 1,002,781. 304,972. 17,000. 472,194. 17,166. 1,814,113. 0. 2PRES/CEO EX-OFFICIO W/VOTE (ii) 0. 0. 0. 0. 0. 0. 0. ALYSON SPAULDING(i) 370,846. 0. 22,917. 151,728. 14,031. 559,522. 0. 3GENERAL COUNSEL (ii) 0. 0. 0. 0. 0. 0. 0. DAVID HUGHES, MD(i) 589,825. 47,000. 7,000. 196,116. 5,853. 845,794. 0. 4EVP, CMO (ii) 0. 0. 0. 0. 0. 0. 0. TONI BOOKER(i) 349,284. 77,500. 121,038. 36,471. 6,288. 590,581. 114,038. 5EVP, CHIEF HUMAN RESOURCES OFC (ii) 0. 0. 0. 0. 0. 0. 0. JONATHAN SWIATKOWSKI(i) 460,545. 104,225. 7,000. 152,247. 14,215. 738,232. 0. 6EVP, CFO (ii) 0. 0. 0. 0. 0. 0. 0. JAMAL GHANI(i) 665,928. 0. 7,000. 23,300. 14,559. 710,787. 0. 7EVP, COO (ii) 0. 0. 0. 0. 0. 0. 0. DONALD BOYD(i) 424,166. 85,000. 110,644. 23,300. 14,262. 657,372. 85,644. 8SVP BUSINESS DEVELOPMENT (ii) 0. 0. 0. 0. 0. 0. 0. CHRISTOPHER LANE(i) 388,506. 65,000. 2,000. 23,300. 14,130. 492,936. 0. 9SVP OPERATIONS MFS, DMH (ii) 0. 0. 0. 0. 0. 0. 0. CHERYL KLASS(i) 524,169. 100,000. 7,000. 465,805. 6,539. 1,103,513. 0. 10SVP OPERATIONS BGMC (ii) 0. 0. 0. 0. 0. 0. 0. ALLEGRA JAROS(i) 363,302. 60,000. 2,000. 23,300. 14,096. 462,698. 0. 11SVP OPERATIONS WCHOB (ii) 0. 0. 0. 0. 0. 0. 0. AARON HOFFMAN, MD(i) 938,743. 0. 0. 29,077. 14,647. 982,467. 0. 12EMPLOYED PHYSICIAN (ii) 0. 0. 0. 0. 0. 0. 0. CHRISTOPHER MALLAVARAPU(i) 919,404. 0. 0. 36,481. 14,460. 970,345. 0. 13EMPLOYED PHYSICIAN (ii) 0. 0. 0. 0. 0. 0. 0. JOHN BUTSCH(i) 613,395. 0. 0. 30,756. 14,388. 658,539. 0. 14EMPLOYED PHYSICIAN (ii) 0. 0. 0. 0. 0. 0. 0. CARROLL HARMON(i) 638,019. 0. 0. 7,518. 1,095. 646,632. 0. 15EMPLOYED PHYSICIAN (ii) 0. 0. 0. 0. 0. 0. 0. KAVEH VALI, MD(i) 561,417. 0. 0. 28,987. 1,029. 591,433. 0. 16EMPLOYED PHYSICIAN (ii) 0. 0. 0. 0. 0. 0. 0. Schedule J (Form 990) 2015
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Schedule J (Form 990) 2015 Page 2 Part II Officers, Directors, Trustees, Key Employees, and Highest Compensated Employees. Use duplicate copies if additional space is needed. For each individual whose compensation must be reported on Schedule J, report compensation from the organization on row (i) and from related organizations, described in the instructions, on row (ii). Do not list any individuals that are not listed on Form 990, Part VII. Note: The sum of columns (B)(i)-(iii) for each listed individual must equal the total amount of Form 990, Part VII, Section A, line 1a, applicable column (D) and (E) amounts for that individual.
(B) Breakdown of W-2 and/or 1099-MISC compensation (C) Retirement and (D) Nontaxable (E) Total of columns (F) Compensation other deferred benefits (B)(i)-(D) in column (B) reported (A) Name and Title (i) Base (ii) Bonus & incentive (iii) Other compensation compensation compensation reportable as deferred on prior Form 990 compensation
MICHAEL HUGHES(i) 291,575. 37,125. 7,000. 84,588. 614. 420,902. 0. 1SVP, PUBLIC AFFAIRS MARKETING (ii) 0. 0. 0. 0. 0. 0. 0. (i) 2 (ii) (i) 3 (ii) (i) 4 (ii) (i) 5 (ii) (i) 6 (ii) (i) 7 (ii) (i) 8 (ii) (i) 9 (ii) (i) 10 (ii) (i) 11 (ii) (i) 12 (ii) (i) 13 (ii) (i) 14 (ii) (i) 15 (ii) (i) 16 (ii) Schedule J (Form 990) 2015
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Schedule J (Form 990) 2015 Page 3 Part III Supplemental Information Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.
HEALTH OR SOCIAL CLUB DUES
SCHEDULE J, PART I, LINE 1A
AS PART OF THEIR COMPENSATION PACKAGE, OFFICERS AND KEY EMPLOYEES OF THE
ORGANIZATION ARE ENTITLED TO CHOOSE AS AN EXECUTIVE PERK THE BENEFIT OF
BUSINESS RELATED SOCIAL DUES OR INITIATION FEES.
SEVERANCE PAYMENTS
SCHEDULE J, PART I, LINE 4A
ONE FORMER EMPLOYEE LISTED ON FORM 990, PART VII, SECTION A, RECEIVED
SEVERANCE PAYMENTS DURING 2015:
JAMES KASKIE, FORMER CEO, $1,109,433
EXECUTIVE DEFERRED RETIREMENT PLAN
SCHEDULE J, PART I, LINE 4B
DURING THE YEAR, THE FOLLOWING OFFICERS AND KEY EMPLOYEES LISTED ON FORM
990, PART VII, SECTION A PARTICIPATED IN THE EXECUTIVE DEFERRED
RETIREMENT PLAN: JODY LOMEO, JAMAL GHANI, JONATHAN SWIATKOWSKI, TONI
BOOKER, DAVID HUGHES, MD, DONALD BOYD, MICHAEL HUGHES AND CHERYL KLASS.
Schedule J (Form 990) 2015
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Schedule J (Form 990) 2015 Page 3 Part III Supplemental Information Complete this part to provide the information, explanation, or descriptions required for Part I, lines 1a, 1b, 3, 4a, 4b, 4c, 5a, 5b, 6a, 6b, 7, and 8, and for Part II. Also complete this part for any additional information.
EMPLOYER AND EMPLOYEE CONTRIBUTIONS DURING THE YEAR TO THIS PLAN HAVE
BEEN REPORTED, AS REQUIRED, ON SCHEDULE J, PART II COLUMNS (B) (III) AND
(C). DURING 2015, THE FOLLOWING OFFICERS AND KEY EMPLOYEES RECEIVED
PAYMENTS UNDER AN EXECUTIVE DEFERRED RETIREMENT PLAN:
TONI BOOKER $114,038
DONALD BOYD $85,644
Schedule J (Form 990) 2015
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5E1505 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 85 SCHEDULE L Transactions With Interested Persons OMB No. 1545-0047 (Form 990 or 990-EZ) Complete if the organization answered "Yes" on Form 990, Part IV, line 25a, 25b, 26, 27, 28a, 28b, or 28c, or Form 990-EZ, Part V, line 38a or 40b. Open To Public Department of the Treasury Attach to Form 990 or Form 990-EZ. Internal Revenue Service Information about Schedule L (Form 990 or 990-EZ) and its instructions is at www.irs.gov/form990. Inspection Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 Part I Excess Benefit Transactions (section 501(c)(3), section 501(c)(4), and 501(c)(29) organizations only). Complete if the organization answered “Yes” on Form 990, Part IV, line 25a or 25b, or Form 990-EZ, Part V, line 40b.
(b) Relationship between disqualified person and (d) Corrected? 1 (a) Name of disqualified person (c) Description of transaction organization Yes No (1) (2) (3) (4) (5) (6) 2 Enter the amount of tax incurred by the organization managers or disqualified persons during the year under section 4958 $ 3 Enter the amount of tax, if any, on line 2, above, reimbursed by the organization $
Part II Loans to and/or From Interested Persons. Complete if the organization answered "Yes" on Form 990-EZ, Part V, line 38a or Form 990, Part IV, line 26; or if the organization reported an amount on Form 990, Part X, line 5, 6, or 22.
(a) Name of interested person (b) Relationship (c) Purpose of (d) Loan to or (e) Original (f) Balance due (g) In default? (h) Approved (i) Written with organization loan from the principal amount by board or agreement? organization? committee?
To From Yes No Yes No Yes No (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Total $ Part III Grants or Assistance Benefiting Interested Persons. Complete if the organization answered “Yes” on Form 990, Part IV, line 27. (a) Name of interested person (b) Relationship between interested (c) Amount of assistance (d) Type of assistance (e) Purpose of assistance person and the organization (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) For Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Schedule L (Form 990 or 990-EZ) 2015
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Schedule L (Form 990 or 990-EZ) 2015 Page 2 Part IV Business Transactions Involving Interested Persons. Complete if the organization answered "Yes" on Form 990, Part IV, line 28a, 28b, or 28c.
(a) Name of interested person (b) Relationship between (c) Amount of (d) Description of transaction (e) Sharing of interested person and the transaction organization's organization revenues?
Yes No
(1) SUSAN EVANS SEE PART V 81,439. SEE PART V X (2) (3) (4) (5) (6) (7) (8) (9) (10) Part V Supplemental Information Provide additional information for responses to questions on Schedule L (see instructions).
BUSINESS TRANSACTIONS INVOLVING INTERESTED PERSONS
SCHEDULE L, PART IV
SUSAN EVANS, COLUMN B - RELATIONSHIP BETWEEN INTERESTED PERSON AND
ORGANIZATION: SUSAN EVANS IS A FAMILY MEMBER OF A CURRENT BOARD MEMBER OF
THE ORGANIZATION, EVAN EVANS, MD, WHO RECEIVED COMPENSATION FROM THE
ORGANIZATION IN EXCESS OF $10,000. COLUMN D - DESCRIPTION OF THE
TRANSACTION: DURING 2015, THE ORGANIZATION PAID THE INTERESTED PERSON
(SUSAN EVANS) IN THE NORMAL COURSE OF BUSINESS FOR PERFORMANCE OF
SERVICES AS A UTILIZATION REVIEW COORDINATOR.
JSA 5E1507 1.000 Schedule L (Form 990 or 990-EZ) 2015 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 87 SCHEDULE M Noncash Contributions OMB No. 1545-0047 (Form 990) Complete if the organizations answered "Yes" on Form 990, Part IV, lines 29 or 30. Attach to Form 990. Department of the Treasury Open To Public Internal Revenue Service Information about Schedule M (Form 990) and its instructions is at www.irs.gov/form990. Inspection Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 Part I Types of Property (a) (b) (c) (d) Noncash contribution Check if Number of contributions or Method of determining amounts reported on applicable items contributed Form 990, Part VIII, line 1g noncash contribution amounts 1 Art - Works of art 2 Art - Historical treasures 3 Art - Fractional interests 4 Books and publications 5 Clothing and household goods 6 Cars and other vehicles 7 Boats and planes 8 Intellectual property 9 Securities - Publicly traded 10 Securities - Closely held stock 11 Securities - Partnership, LLC, or trust interests 12 Securities - Miscellaneous 13 Qualified conservation contribution - Historic structures 14 Qualified conservation contribution - Other 15 Real estate - Residential 16 Real estate - Commercial 17 Real estate - Other 18 Collectibles 19 Food inventory 20 Drugs and medical supplies 21 Taxidermy 22 Historical artifacts 23 Scientific specimens 24 Archeological artifacts 25 Other ( ATCH 1 ) 2. 4,354,054. 26 Other ( ) 27 Other ( ) 28 Other ( ) 29 Number of Forms 8283 received by the organization during the tax year for contributions for which the organization completed Form 8283, Part IV, Donee Acknowledgement 29 Yes No 30a During the year, did the organization receive by contribution any property reported in Part I, lines 1 through 28, that it must hold for at least three years from the date of the initial contribution, and which is not required to be used for exempt purposes for the entire holding period? 30a X b If “Yes,” describe the arrangement in Part II. 31 Does the organization have a gift acceptance policy that requires the review of any non-standard contributions? 31 X 32a Does the organization hire or use third parties or related organizations to solicit, process, or sell noncash contributions? 32a X b If “Yes,” describe in Part II. 33 If the organization did not report an amount in column (c) for a type of property for which column (a) is checked, describe in Part II. For Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule M (Form 990) (2015)
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5E1298 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 88 KALEIDA HEALTH 16-1533232 Schedule M (Form 990) (2015) Page 2 Part II Supplemental Information. Complete this part to provide the information required by Part I, lines 30b, 32b, and 33, and whether the organization is reporting in Part I, column (b), the number of contributions, the number of items received, or a combination of both. Also complete this part for any additional information. ATTACHMENT 1
SCHEDULE M, PART I - OTHER NONCASH CONTRIBUTIONS
(B) NUMBER OF (C) REVENUES (D) METHOD OF DESCRIPTION (A) CHECK CONTRIBUTIONS REPORTED DETERMINING
VARIOUS MEDICAL EQUIPMENT X 2. 4,354,054. REPLACEMENT COST
TOTALS 2. 4,354,054.
JSA Schedule M (Form 990) (2015)
5E1508 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 89 OMB No. 1545-0047 SCHEDULE O Supplemental Information to Form 990 or 990-EZ (Form 990 or 990-EZ) Complete to provide information for responses to specific questions on Form 990 or 990-EZ or to provide any additional information. Open to Public Department of the Treasury Internal Revenue Service Attach to Form 990 or 990-EZ. Inspection Name of the organization Employer identification number KALEIDA HEALTH 16-1533232
ORGANIZATION'S MISSION
KALEIDA HEALTH IS THE LARGEST HEALTHCARE PROVIDER IN WNY, SERVING THE
AREA'S 8 COUNTIES WITH COMPREHENSIVE SERVICES & PROGRAMS PROVIDED AT 4
ACUTE CARE, 2 LT CARE, AS WELL AS OUTPATIENT & PRIMARY CARE SITES.
REVIEW PROCESS FOR FORM 990
FORM 990, PART VI, SECTION B, LINE 11B
ORGANIZATION'S MANAGEMENT (A TEAM COMPRISED OF REPRESENTATIVES OF THE
FINANCE, HUMAN RESOURCES AND LEGAL DEPARTMENTS) IN CONSULTATION WITH THE
ORGANIZATION'S TAX ADVISORS, KPMG, REVIEW THE FORM 990. THE FINANCIAL
REVIEW IS BASED ON THE ORGANIZATION'S AUDITED FINANCIAL STATEMENTS FOR
THE RELEVANT TIME PERIOD. BEFORE THE FORM 990 IS FILED WITH THE IRS, THE
FINANCE COMMITTEE OF THE ORGANIZATION'S BOARD OF DIRECTORS REVIEWS THE
FORM 990 AND PROVIDES A COPY OF THE SAME TO THE ORGANIZATION'S FULL BOARD
OF DIRECTORS.
CONFLICT OF INTEREST POLICY
FORM 990, PART VI, SECTION B, LINE 12C
UPON EMPLOYMENT AND ANNUALLY THEREAFTER EACH KEY EMPLOYEE AND OFFICER OF
THE ORGANIZATION IS REQUIRED TO COMPLETE A CONFLICT OF INTEREST AND
DISCLOSURE FORM, PROVIDING SUFFICIENT INFORMATION ABOUT HIS/HER PERSONAL
INTERESTS AND RELATIONSHIPS SO THE ORGANZATION CAN (1) DETERMINE WHETHER
ANY POTENTIAL OR ACTUAL CONFLICTS OF INTEREST MAY EXIST, AND (2) MONITOR
WORK OR SERVICE ASSIGNMENTS TO AVOID PLACING THE KEY EMPLOYEE, OFFICER OR
For Privacy Act and Paperwork Reduction Act Notice, see the Instructions for Form 990 or 990-EZ. Schedule O (Form 990 or 990-EZ) (2015) JSA 5E1227 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 90 Schedule O (Form 990 or 990-EZ) 2015 Page 2 Name of the organization Employer identification number KALEIDA HEALTH 16-1533232
DIRECTOR IN A POSITION WHERE THERE MAY BE POTENTIAL, ACTUAL, OR EVEN
APPEARANCE, OF A CONFLICT OF INTEREST OR A QUESTION OF OBJECTIVITY. THE
COMPLETED CONFLICTS OF INTEREST AND DISCLOSURE FORMS FOR DIRECTORS ARE
RETURNED TO THE ORGANIZATION.
COMPENSATION APPROVAL PROCESS
FORM 990,PART VI, SECTION B, QUESTION 15A AND B
ON A REGULAR BASIS, THE ORGANIZATION PROVIDES DOCUMENTATION TO THE
COMPENSATION COMMITTEE OF THE BOARD WITH RESPECT TO THE COMPENSATION OF
THE ORGANIZATION'S OFFICERS AND KEY EMPLOYEES FOR REVIEW AND APPROVAL.
SUCH INFORMATION INCLUDES COMPARABLE DATA FROM SIMILAR SIZE TAX-EXEMPT
ORGANIZATIONS IN THE WESTERN NEW YORK COMMUNITY AS WELL AS COMPENSATION
FOR THESE POSITIONS (AS DISCLOSED ON FORM 990) WITH OTHER ORGANIZATIONS
IN THE HEALTH CARE INDUSTRY THAT ARE OF SIMILAR SIZE, DEMOGRAPHICS AND
GEOGRAPHY. REVIEW AND APPROVAL OF THE COMPENSATION ARRANGEMENT BY THE
OFFICERS/EXECUTIVE COMMITTEE IS DOCUMENTED.
ACCESS TO ORGANIZATIONAL DOCUMENTS
FORM 990, PART VI, SECTION C, QUESTION 19
THE ORGANIZATION MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST
POLICY AND FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC UPON REQUEST AT
ITS OFFICE AT 726 EXCHANGE STREET, SUITE 200, BUFFALO, NY 14210. A
NOMINAL FEE IS CHARGED IF COPIES ARE REQUESTED.
FORM 990, PART XI
OTHER CHANGES IN NET ASSETS OR FUND BALANCES
JSA Schedule O (Form 990 or 990-EZ) 2015 5E1228 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 91 Schedule O (Form 990 or 990-EZ) 2015 Page 2 Name of the organization Employer identification number KALEIDA HEALTH 16-1533232
INVESTMENTS IN JOINT VENTURES, NET (87,826,975)
MINORITY INTEREST IN SUBSIDIARY (143,514)
INCREASE IN PENSION LIABILITY 15,196,274
TRANSFER FROM KALEIDA FOUNDATIONS 33,898,212
OTHER TRANSFERS, NET (177,425)
CHANGE IN VALUE OF FOUNDATIONS (32,075,887)
------
TOTAL (71,129,315) ATTACHMENT 1 FORM 990, PART III, LINE 1 - ORGANIZATION'S MISSION
KALEIDA HEALTH IS A VOLUNTARY, NOT-FOR-PROFIT; NEW YORK STATE
DEPARTMENT OF HEALTH ARTICLE 28 LICENSED HOSPITAL-BASED HEALTHCARE
DELIVERY SYSTEM SERVICING THE COMMUNITIES OF WESTERN NEW YORK STATE
AT VARIOUS LEVELS AND WITH FACILITIES IN MULTIPLE LOCATIONS
THROUGHOUT THE REGION. KALEIDA HEALTH INCLUDES THE BUFFALO GENERAL
MEDICAL CENTER (BUFFALO GENERAL), MILLARD FILLMORE SUBURBAN HOSPITAL
(MILLARD SUBURBAN), WOMEN AND CHILDREN'S HOSPITAL OF BUFFALO (WOMEN &
CHILDREN'S), AND DEGRAFF MEMORIAL HOSPITAL (DEGRAFF). IN ADDITION TO
THE FOUR KALEIDA HEALTH (KALEIDA) HOSPITALS, KALEIDA OPERATES TWO
SKILLED NURSING FACILITIES, AND NUMEROUS OUTPATIENT CLINICS. THE
ABOVE FACILITIES OPERATE UNDER ONE TAX IDENTIFICATION NUMBER. OUR
FAMILY OF HEALTH CARE ORGANIZATIONS IS BLENDED TOGETHER INTO ONE
FRAMEWORK FOR LEADERSHIP, GOVERNANCE, SHARED SERVICES, FINANCIAL
INFRASTRUCTURE AND INFORMATION TECHNOLOGY PLATFORMS. COLLECTIVELY,
KALEIDA HEALTH'S MARKET SHARE IS 31.7% IN WESTERN NEW YORK, 40.4% IN
ERIE COUNTY AND 29.3% IN NIAGARA COUNTY. ANNUALLY ONE MILLION
COMBINED INPATIENT, EMERGENCY DEPARTMENT AND OUTPATIENT VISITS OCCUR
JSA Schedule O (Form 990 or 990-EZ) 2015 5E1228 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 92 Schedule O (Form 990 or 990-EZ) 2015 Page 2 Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 1 (CONT'D) FORM 990, PART III, LINE 1 - ORGANIZATION'S MISSION
AT THE HEALTH CARE FACILITIES IN THE KALEIDA HEALTH SYSTEM, WHICH
EMPLOYS APPROXIMATELY 9,300 STAFF AND HAVE APPROXIMATELY 2,300
MEDICAL STAFF MEMBERS. DURING 2015, THERE WERE 54,935 INPATIENT
DISCHARGES, OF WHICH 24% WERE MEDICAID AND MEDICAID MANAGED, 40%
MEDICARE AND MEDICARE MANAGED CARE AND 1% WERE UNINSURED.
KALEIDA HEALTH'S MISSION IS TO ADVANCE THE HEALTH OF OUR COMMUNITY.
OUR VISION IS TO PROVIDE COMPASSIONATE, HIGH-VALUE, QUALITY CARE,
IMPROVING HEALTH IN WESTERN NEW YORK AND BEYOND, EDUCATING FUTURE
HEALTH CARE LEADERS AND DISCOVERING INNOVATIVE WAYS TO ADVANCE
MEDICINE. OUR VALUES CLEARLY STATE WHO WE ARE AND HOW WE PERFORM OUR
WORK:
CENTERED: REMAIN CENTERED AROUND THE PATIENT AND FAMILY.
ACCOUNTABLE: BE ACCOUNTABLE TO PATIENTS AND EACH OTHER.
RESPECT: SHOW RESPECT AND INTEGRITY.
EXCELLENCE: PROVIDE EXCELLENCE IN ALL WE DO.
KALEIDA HEALTH'S PROGRAMS AND AFFILIATES ARE LICENSED BY THE STATE OF
NEW YORK DEPARTMENT OF HEALTH AND ACCREDITED BY DNV. KALEIDA IS
CERTIFIED BY THE US DEPARTMENT OF HEALTH AND HUMAN SERVICES FOR
PARTICIPATION IN MEDICARE AND MEDICAID. THE ACCREDITATION COUNSEL FOR
GRADUATE MEDICAL EDUCATION APPROVES ALL RESIDENCY PROGRAMS FOR
PHYSICIANS, AND THE AMERICAN DENTAL ASSOCIATION APPROVES ITS DENTAL
AND ORAL SURGERY PROGRAMS. KALEIDA IS ALSO A MEMBER OF THE COUNCIL OF
TEACHING HOSPITALS, THE AMERICAN DENTAL ASSOCATION, THE AMERICAN
JSA Schedule O (Form 990 or 990-EZ) 2015 5E1228 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 93 Schedule O (Form 990 or 990-EZ) 2015 Page 2 Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 1 (CONT'D) FORM 990, PART III, LINE 1 - ORGANIZATION'S MISSION
MEDICAL ASSOCATION AND THE GREATER NEW YORK HOSPITAL ASSOCATION.
OPERATION OF EMERGENCY ROOMS:
KALEIDA HEALTH OPERATES FOUR EMERGENCY ROOMS, ONE IN EACH OF THE
ACUTE CARE HOSPITALS, GENERATING A TOTAL OF 167,395 PATIENT VISITS
DURING 2015. THE EMERGENCY DEPARTMENTS, WHICH OPERATE 24 HOURS A DAY,
SEVEN DAYS EACH WEEK, ARE OPEN TO ANYONE, REGARDLESS OF THEIR ABILITY
TO PAY FOR SERVICES.
BOARD OF DIRECTORS AND COMMUNITY GUIDANCE:
KALEIDA HEALTH MAINTAINS COMMUNITY CONTROL OVER THE CORPORATION
THROUGH ITS BOARD OF DIRECTORS, COMPRISED OF COMMUNITY AND FAITH
LEADERS, AND LEADERS IN BUSINESS AND INDUSTRY, HEALTHCARE AND
PHYSICIANS REPRESENTING THE MEDICAL STAFF OF KALEIDA HEALTH. THE
MAJORITY OF THE DIRECTORS RESIDE IN WESTERN NEW YORK AND EACH
DIRECTOR SERVES A THREE-YEAR TERM.
OPEN MEDICAL STAFF:
AS CONFERRED BY THE BOARD OF DIRECTORS, MEDICAL STAFF MEMBERSHIP IS
OFFERED TO PROFESSIONALLY COMPETENT PHYSICIANS, DENTISTS, PODIATRISTS
AND OTHER SPECIFIED INDIVIDUALS, WHO CONTINUOUSLY MEET THE
QUALIFICATIONS, STANDARDS AND REQUIREMENTS OUTLINED IN THE BYLAWS,
RULES AND REGULATIONS, POLICIES OF THE MEDICAL STAFF AND KALEIDA
HEALTH, CONSISTENT WITH THE NEEDS OF KALEIDA HEALTH'S PATIENTS. STAFF
MEMBERSHIP OR PARTICULAR CLINICAL PRIVILEGES SHALL NOT BE DENIED ON
THE BASIS OF AGE, SEX, SEXUAL ORIENTATON, RACE, COLOR, CREED,
JSA Schedule O (Form 990 or 990-EZ) 2015 5E1228 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 94 Schedule O (Form 990 or 990-EZ) 2015 Page 2 Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 1 (CONT'D) FORM 990, PART III, LINE 1 - ORGANIZATION'S MISSION
NATIONAL ORIGIN, A DISABILITY UNRELATED TO THE ABILITY TO FULFILL
PATIENT CARE AND MEDICAL STAFF RESPONSIBILITIES OR ANY OTHER
CRITERION UNRELATED TO THE EFFICIENT DELIVERY OF QUALITY PATIENT
CARE, TO PROFESSIONAL QUALIFICATIONS OR TO THE NEEDS OF THE
COMMUNITY, OR TO THE PURPOSES, NEEDS AND CAPABILITIES OF KALEIDA
HEALTH. EVERY MEMBER OF THE MEDICAL STAFF ASSISTS THE HOSPITALS IN
FULFILLING OUR MISSION AND RESPONSIBILITY TO PROVIDE EMERGENCY AND
UNCOMPENSATED CARE FOR THOSE IN NEED.
USE OF SURPLUS FUNDS:
SURPLUS FUNDS ARE USED TO FURTHER THE MISSION AND OPERATIONS OF
KALEIDA HEALTH, SUCH AS REINVESTING IN COMMUNITY BENEFIT PROGRAMS,
AND MAKING IMPROVEMENTS IN FACILITIES, PATIENT CARE, MEDICAL, NURSING
AND ALLIED HEALTH TRAINING, EDUCATION AND RESEARCH IN SUPPORT OF THE
HEALTH NEEDS OF THE COMMUNITY.
COMMUNITY BENEFIT PROGRAMS AND SERVICES:
KALEIDA HEALTH OFFERS NUMEROUS COMMUNITY BENEFIT PROGRAMS AND
SERVICES IN RESPONSE TO THE COMMUNITY'S NEEDS, BY IMPROVING ACCESS TO
CARE, IMPROVE PUBLIC HEALTH, ADVANCE KNOWLEDGE AND RELIEVE GOVERNMENT
PROGRAMS. THESE PROGRAMS ARE CONDUCTED IN COMMUNITY-BASED SETTINGS
SUCH AS SCHOOLS, CHURCHES, COMMUNITY CENTERS, SENIOR CENTERS AND
PROGRAMS ARE ALSO OFFERED AT KALEIDA'S HOSPITAL CAMPUSES AND
FACILITIES. COMMUNITY BENEFIT PROGRAMS AND SERVICES INCLUDE HEALTH
FAIRS, HEALTH SCREENINGS, HEALTH EDUCATION LECTURES AND WORKSHOPS FOR
COMMUNITY GROUPS AND THE GENERAL PUBLIC, SCHOOL HEALTH EDUCATION
JSA Schedule O (Form 990 or 990-EZ) 2015 5E1228 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 95 Schedule O (Form 990 or 990-EZ) 2015 Page 2 Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 1 (CONT'D) FORM 990, PART III, LINE 1 - ORGANIZATION'S MISSION
PROGRAMS, AND CONSUMER HEALTH INFORMATION IN THE KALEIDA HEALTH
LIBRARIES. KALEIDA ALSO OFFERS A NUMBER OF SUBSIDIZED HEALTH SERVICES
SUCH AS OUTPATIENT CLINICS, LONG-TERM CARE SERVICES, WOMEN'S HEALTH
CENTERS, DIALYSIS SERVICES, BEHAVIORAL HEALTH SERVICES, SCHOOL-BASED
HEALTH CENTERS, EARLY CHILDHOOD PROGRAM, EARLY INTERVENTION SERVICES,
FAMILY PLANNING SERVICES, WESTERN NEW YORK CLINICAL INFORMATION
EXCHANGE AND HEALTH-E-LINK AND DIAGNOSTIC, THERAPEUTIC AND
REHABILITATION SERVICES FOR CHILDREN WITH SPECIAL NEEDS. KALEIDA'S
HOSPITALS SERVE AS A MAJOR TEACHING AFFILIATE OF THE STATE UNIVERSITY
OF NEW YORK AT BUFFALO'S SCHOOL OF MEDICINE AND BIOMEDICAL SCIENCES
AND DENTAL MEDICINE, WITH TRAINING TO 400 MEDICAL AND DENTAL
RESIDENTS EACH YEAR. KALEIDA IS INVOLVED IN AND SPONSORS RESEARCH
PROJECTS, AND WE PROVIDE LOAN FORGIVENESS FOR PHYSICIANS TO ESTABLISH
OR JOIN EXISTING PRACTICES THAT SERVE THE UNDERSERVED COMMUNITIES OF
BUFFALO AND WESTERN NEW YORK. KALEIDA OFFERS CLINICAL TRAINING
FACILITIES AND SUPPORT FOR NURSING AND A NUMBER OF ALLIED HEALTH
PROFESSIONAL TRAINING PROGRAMS AT LOCAL COLLEGES AND UNIVERSITIES,
AND OTHER PROFESSIONAL DEVELOPMENT/CONTINUING EDUCATION TRAINING
PROGRAMS FOR COLLEAGUES FROM HEALTH CARE ORGANIZATIONS ACROSS THE
REGION.
ATTACHMENT 2
990, PART VII- COMPENSATION OF THE FIVE HIGHEST PAID IND. CONTRACTORS
NAME AND ADDRESS DESCRIPTION OF SERVICES COMPENSATION
SODEXO MANAGEMENT, INC. CLEANING & LAUNDRY 4,555,816. PO BOX 81049
JSA Schedule O (Form 990 or 990-EZ) 2015 5E1228 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 96 Schedule O (Form 990 or 990-EZ) 2015 Page 2 Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 2 (CONT'D)
990, PART VII- COMPENSATION OF THE FIVE HIGHEST PAID IND. CONTRACTORS
NAME AND ADDRESS DESCRIPTION OF SERVICES COMPENSATION
WOBURN, MA 01813-1049
WNY RADIOLOGY, LLC RADIOLOGY SVCS 5,379,031. PO BOX 4029 BUFFALO, NY 14240
MACRO HELIX, INC 340B SOFTWARE FEES 1,658,959. PO BOX 742256 ATLANTA, GA 30374-2256
WE CARE TRANSPORTATION PATIENT TRANSPORT 1,377,037. 401 EAST AMHERST STREET BUFFALO, NY 14215
PST SERVICES INC. MEDICAL BILLING 1,287,159. PO BOX 742526 ATLANTA, GA 30374-2526
ATTACHMENT 3 FORM 990, PART VIII - INVESTMENT INCOME
(A) (B) (C) (D) TOTAL RELATED OR UNRELATED EXCLUDED DESCRIPTION REVENUE EXEMPT REVENUE BUSINESS REV. REVENUE
INVESTMENT INCOME 5,108,876. -34,371. 91,854. 5,051,393.
TOTALS 5,108,876. -34,371. 91,854. 5,051,393.
ATTACHMENT 4
FORM 990, PART IX - OTHER FEES
(A) (B) (C) (D) TOTAL PROGRAM MANAGEMENT FUNDRAISING DESCRIPTION FEES SERVICE EXP. AND GENERAL EXPENSES
CONTRACTED PHYSICIAN FEES 67,363,346. 65,105,387. 2,257,959.
OTHER PURCHASED SERVICES 24,865,985. 21,589,120. 3,276,865.
INTERNS & RESIDENTS FEES 24,517,706. 24,517,706.
JSA Schedule O (Form 990 or 990-EZ) 2015 5E1228 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 97 Schedule O (Form 990 or 990-EZ) 2015 Page 2 Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 4 (CONT'D)
FORM 990, PART IX - OTHER FEES
(A) (B) (C) (D) TOTAL PROGRAM MANAGEMENT FUNDRAISING DESCRIPTION FEES SERVICE EXP. AND GENERAL EXPENSES
OTHER 5,815,218. 2,343,022. 3,472,196.
TOTALS 122,562,255. 113,555,235. 9,007,020.
ATTACHMENT 5
FORM 990, PART X - PREPAID EXPENSES AND DEFERRED CHARGES
ENDING DESCRIPTION BOOK VALUE
PREPAID EXPENSES 10,908,230.
TOTALS 10,908,230.
ATTACHMENT 6
FORM 990, PART X - INVESTMENTS - PUBLICLY TRADED SECURITIES
ENDING COST DESCRIPTION BOOK VALUE OR FMV
VAR PUBLICLY TRADED SECURITIES 74,551,845. FMV
TOTALS 74,551,845.
ATTACHMENT 7 FORM 990, PART X - SECURED MORTGAGES AND NOTES PAYABLE
LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 100,253,000. INTEREST RATE: 6.3500 % MATURITY DATE: 02/01/2037 REPAYMENT TERMS: 25 YEARS PURPOSE OF LOAN: FINANCE THE COST OF THE DEVELOPMENT OF THE GVI
BEGINNING BALANCE DUE ...... 91,426,941. ENDING BALANCE DUE ...... 89,481,700.
JSA Schedule O (Form 990 or 990-EZ) 2015 5E1228 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 98 Schedule O (Form 990 or 990-EZ) 2015 Page 2 Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 7 (CONT'D) LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 51,864,100. INTEREST RATE: 5.7300 % MATURITY DATE: 02/01/2037 REPAYMENT TERMS: 25 YEARS PURPOSE OF LOAN: FINANCE THE COST OF DEVELOPMENT OF THE SNF
BEGINNING BALANCE DUE ...... 48,990,015. ENDING BALANCE DUE ...... 47,859,364.
LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 62,235,882. INTEREST RATE: 2.4400 % MATURITY DATE: 08/01/2023 REPAYMENT TERMS: MONTHLY INSTALLMENTS PURPOSE OF LOAN: BGMC MORTGAGE
BEGINNING BALANCE DUE ...... 51,067,573. ENDING BALANCE DUE ...... 45,710,632.
LENDER: M&T BANK ORIGINAL AMOUNT: 7,500,000. INTEREST RATE: 2.2100 % DATE OF NOTE: 01/01/2001 MATURITY DATE: 01/01/2026 REPAYMENT TERMS: MONTHLY INSTALLMENTS PURPOSE OF LOAN: 296 NIAGARA STREET
BEGINNING BALANCE DUE ...... 1,040,704. ENDING BALANCE DUE ...... 740,704.
JSA Schedule O (Form 990 or 990-EZ) 2015 5E1228 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 99 Schedule O (Form 990 or 990-EZ) 2015 Page 2 Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 7 (CONT'D) LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 83,544,370. INTEREST RATE: 3.2900 % MATURITY DATE: 04/01/2020 REPAYMENT TERMS: MONTHLY INSTALLMENTS PURPOSE OF LOAN: MFH REFINANCING
BEGINNING BALANCE DUE ...... 25,071,721. ENDING BALANCE DUE ...... 19,651,549.
LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 48,440,328. INTEREST RATE: 4.1800 % MATURITY DATE: 10/01/2042 REPAYMENT TERMS: MONTHLY INSTALLMENTS PURPOSE OF LOAN: FINANCE COST OF DEVELOPMENT OF CHILDREN'S HOSPITAL
BEGINNING BALANCE DUE ...... 14,786,099. ENDING BALANCE DUE ...... 48,440,328.
LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 57,540,000. INTEREST RATE: 4.0000 % MATURITY DATE: 10/01/2033 REPAYMENT TERMS: MONTHLY INSTALLMENTS PURPOSE OF LOAN: IMPROVEMENTS TO MFH ENDING BALANCE DUE ...... 47,851,439.
JSA Schedule O (Form 990 or 990-EZ) 2015 5E1228 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 100 Schedule O (Form 990 or 990-EZ) 2015 Page 2 Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 ATTACHMENT 7 (CONT'D) LENDER: PRUDENTIAL HUNTOON PAIGE ASSOC. ORIGINAL AMOUNT: 18,290,000. INTEREST RATE: 3.9500 % MATURITY DATE: 02/01/2032 REPAYMENT TERMS: MONTHLY INSTALLMENTS PURPOSE OF LOAN: CARDIAC CATH LAB EQUIPMENT ENDING BALANCE DUE ...... 14,254,405.
TOTAL BEGINNING MORTGAGES AND OTHER NOTES PAYABLE 232,383,053.
TOTAL ENDING MORTGAGES AND OTHER NOTES PAYABLE 313,990,121.
JSA Schedule O (Form 990 or 990-EZ) 2015 5E1228 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 101 KALEIDA HEALTH 16-1533232 SCHEDULE R Related Organizations and Unrelated Partnerships OMB No. 1545-0047 (Form 990) Complete if the organization answered "Yes" on Form 990, Part IV, line 33, 34, 35b, 36, or 37. Attach to Form 990. Open to Public Department of the Treasury Information about Schedule R (Form 990) and its instructions is at www.irs.gov/form990. Internal Revenue Service Inspection Name of the organization Employer identification number KALEIDA HEALTH 16-1533232 Part I Identification of Disregarded Entities Complete if the organization answered "Yes" on Form 990, Part IV, line 33.
(a) (b) (c) (d) (e) (f) Name, address, and EIN (if applicable) of disregarded entity Primary activity Legal domicile (state Total income End-of-year assets Direct controlling or foreign country) entity (1) KALEIDA MCO LLC 16-1570311 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 DORMANT NY 0. 0. KH (2) KALEIDA IPA LLC 16-1570380 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 DORMANT NY 0. 0. KH (3) KALEIDA WNYI LLC 45-3189404 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 HEALTH CARE NY 593,595. 4,479,835. KH (4)
(5)
(6)
Identification of Related Tax-Exempt Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had Part II one or more related tax-exempt organizations during the tax year.
(a) (b) (c) (d) (e) (f) (g) Name, address, and EIN of related organization Primary activity Legal domicile (state Exempt Code section Public charity status Direct controlling Section 512(b)(13) controlled or foreign country) (if section 501(c)(3)) entity entity? Yes No (1) MILLARD FILLMORE AMBULATORY SURGER CTR 16-1307129 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 SUPPORT ORG NY 501(C)(3) 11A KH X (2) VNA HOME CARE SERVICES 16-1491203 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 HOME HLTH CAR NY 501(C)(3) 9 KH X (3) VNA OF WESTERN NEW YORK 16-0743214 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 HOME HLTH CAR NY 501(C)(3) 9 KH X (4) VISK 22-2738425 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 SUPPORT ORG NY 501(C)(3) 9 KH X (5) KALEIDA HEALTH FOUNDATION 16-1579143 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 FUNDRAISING NY 501(C)(3) 7 KH X (6) THE WOMEN & CHILDREN'S HOSP OF BFLO FDN 16-1332044 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 FUNDRAISING NY 501(C)(3) 7 KH X (7)
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Schedule R (Form 990) 2015
JSA
5E1307 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 102 KALEIDA HEALTH 16-1533232
Schedule R (Form 990) 2015 Page 2 Part III Identification of Related Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year. (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) Name, address, and EIN of Primary activity Legal Direct controlling Predominant Share of total Share of end-of- Disproportionate Code V-UBI General or Percentage income (related, related organization domicile entity income year assets allocations? amount in box 20 managing ownership unrelated, (state or excluded from of Schedule K-1 partner? foreign tax under (Form 1065) country) sections 512-514) Yes No Yes No
(1) HARLEM ROAD LEASING, LLC 20-55 3435 MAIN STREET BUFFALO, NY 1 EQUIPMENT LEASING NY KALEIDA HEALTH UNRELATED 91,854. 42,676. X 91,854. X 50.0000 (2) AMTON IMAGING, LLC 26-2925470 199 PARK CLUB LANE, SUITE 300 HEALTH CARE NY KALEIDA WNYI RELATED 335,698. 470,282. X 0. X 50.0000 (3) SITE E, LLC 27-2124795 726 EXCHANGE STREET, SUITE 200 REAL ESTATE MGMT NY KPI EXCLUDED 113,375. 1,647,935. X 0. X 50.1601 (4) MSFC, LLC 26-1582864 100 HIGH STREET BUFFALO, NY 14 HEALTH CARE NY KALEIDA HEALTH EXCLUDED 249,427. 1,798,806. X 0. X 55.2974 (5) SOUTHTOWNS IMAGING, LLC 47-112 5959 BIG TREE ROAD, SUITE 105 EQUIPMENT LEASING NY KALEIDA WNYI UNRELATED -112,281. 2,792,663. X -362,592. X 70.0000 (6) COLLABORATIVE CARE VENTURES, L 726 EXCHANGE STREET, SUITE 200 HEALTH CARE NY KALEIDA HEALTH EXCLUDED -850. 11,569,269. X 0. X 60.0000 (7) GREAT LAKES MED IMAGING BILLIN 199 PARK CLUB LANE, SUITE 300 MEDICAL BILLING NY KALEIDA WNYI UNRELATED 183,435. 319,996. X 157,923. X 50.0000 Part IV Identification of Related Organizations Taxable as a Corporation or Trust Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year. (a) (b) (c) (d) (e) (f) (g) (h) (i) Name, address, and EIN of related organization Primary activity Legal domicile Direct controlling Type of entity Share of total Share of Percentage Section 512(b)(13) (state or foreign entity (C corp, S corp, or income end-of-year assets ownership controlled country) trust) entity? Yes No (1) KALEIDA PROPERTIES, INC. 22-2738483 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 PROP MGMT SVCS NY KALEIDA HEALTH C CORP 807,678. 18,826,893. 100.0000 X (2) WESTLINK CORPORATION 16-1354421 726 EXCHANGE STREET, SUITE 200 BUFFALO, NY 14210 MED & DIAGN SVCS NY KALEIDA HEALTH C CORP -285. 101,161. 100.0000 X (3) KALEIDA HEALTHNOW, INC. 46-2164089 257 WEST GENESEE STREET BUFFALO, NY 14202 HEALTH CARE NY KALEIDA HEALTH C CORP 4,245. 1,962,474. 50.0000 X (4)
(5)
(6)
(7)
JSA Schedule R (Form 990) 2015 5E1308 1.000
6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 103 KALEIDA HEALTH 16-1533232
Schedule R (Form 990) 2015 Page 2 Part III Identification of Related Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a partnership during the tax year. (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) Name, address, and EIN of Primary activity Legal Direct controlling Predominant Share of total Share of end-of- Disproportionate Code V-UBI General or Percentage income (related, related organization domicile entity income year assets allocations? amount in box 20 managing ownership unrelated, (state or excluded from of Schedule K-1 partner? foreign tax under (Form 1065) country) sections 512-514) Yes No Yes No
(1) HARLEM IMAGING LLC 199 PARK CLUB LN, SUITE 300 IMAGING SERVICES NY KALEIDA WNYI RELATED 186,743. 896,894. X 0. X 50.0000 (2) ALTUS MANAGEMENT LLC 840 AERO DRIVE, SUITE 950 GROUP PURCHASING NY KALEIDA HEALTH EXCLUDED 174,488. 1,823,056. X 0. X 52.1672 (3)
(4)
(5)
(6)
(7)
Part IV Identification of Related Organizations Taxable as a Corporation or Trust Complete if the organization answered "Yes" on Form 990, Part IV, line 34 because it had one or more related organizations treated as a corporation or trust during the tax year. (a) (b) (c) (d) (e) (f) (g) (h) (i) Name, address, and EIN of related organization Primary activity Legal domicile Direct controlling Type of entity Share of total Share of Percentage Section 512(b)(13) (state or foreign entity (C corp, S corp, or income end-of-year assets ownership controlled country) trust) entity? Yes No (1)
(2)
(3)
(4)
(5)
(6)
(7)
JSA Schedule R (Form 990) 2015 5E1308 1.000
6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 104 KALEIDA HEALTH 16-1533232 Schedule R (Form 990) 2015 Page 3 Part V Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule. Yes No 1 During the tax year, did the organization engage in any of the following transactions with one or more related organizations listed in Parts II-IV? a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity 1a X b Gift, grant, or capital contribution to related organization(s) 1b X c Gift, grant, or capital contribution from related organization(s) 1c X d Loans or loan guarantees to or for related organization(s) 1d X e Loans or loan guarantees by related organization(s) 1e X f Dividends from related organization(s) 1f X g Sale of assets to related organization(s) 1g X h Purchase of assets from related organization(s) 1h X i Exchange of assets with related organization(s) 1i X j Lease of facilities, equipment, or other assets to related organization(s) 1j X k Lease of facilities, equipment, or other assets from related organization(s) 1k X l Performance of services or membership or fundraising solicitations for related organization(s) 1l X m Performance of services or membership or fundraising solicitations by related organization(s) 1m X n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) 1n X o Sharing of paid employees with related organization(s) 1o X p Reimbursement paid to related organization(s) for expenses 1p X q Reimbursement paid by related organization(s) for expenses 1q X r Other transfer of cash or property to related organization(s) 1r X s Other transfer of cash or property from related organization(s) 1s X 2 If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds. (a) (b) (c) (d) Name of related organization Transaction Amount involved Method of determining type (a-s) amount involved
(1) VNA HOME CARE SERVICES Q 2,109,779. ACTUAL COST
(2) VNA OF WESTERN NEW YORK Q 14,447,259. ACTUAL COST
(3) VNA OF WESTERN NEW YORK O 222,769. ACTUAL COST
(4) MFSC, LLC J 622,809. ACTUAL COST
(5) MFSC, LLC P 174,542. ACTUAL COST
(6) KALEIDA PROPERTIES, INC. Q 161,817. ACTUAL COST
JSA Schedule R (Form 990) 2015 5E1309 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 105 KALEIDA HEALTH 16-1533232 Schedule R (Form 990) 2015 Page 3 Part V Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule. Yes No 1 During the tax year, did the organization engage in any of the following transactions with one or more related organizations listed in Parts II-IV? a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity 1a b Gift, grant, or capital contribution to related organization(s) 1b c Gift, grant, or capital contribution from related organization(s) 1c d Loans or loan guarantees to or for related organization(s) 1d e Loans or loan guarantees by related organization(s) 1e f Dividends from related organization(s) 1f g Sale of assets to related organization(s) 1g h Purchase of assets from related organization(s) 1h i Exchange of assets with related organization(s) 1i j Lease of facilities, equipment, or other assets to related organization(s) 1j k Lease of facilities, equipment, or other assets from related organization(s) 1k l Performance of services or membership or fundraising solicitations for related organization(s) 1l m Performance of services or membership or fundraising solicitations by related organization(s) 1m n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) 1n o Sharing of paid employees with related organization(s) 1o p Reimbursement paid to related organization(s) for expenses 1p q Reimbursement paid by related organization(s) for expenses 1q r Other transfer of cash or property to related organization(s) 1r s Other transfer of cash or property from related organization(s) 1s 2 If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds. (a) (b) (c) (d) Name of related organization Transaction Amount involved Method of determining type (a-s) amount involved
(1) KALEIDA PROPERTIES, INC. D 4,585,314. ACTUAL COST
(2) SITE E, LLC K 233,450. ACTUAL COST
(3) WCHOB FOUNDATION C 1,260,774. ACTUAL COST
(4) WCHOB FOUNDATION S 23,586,389. ACTUAL COST
(5) WCHOB FOUNDATION P 120,247. ACTUAL COST
(6) KALEIDA HEALTH FOUNDATION C 2,230,471. ACTUAL COST
JSA Schedule R (Form 990) 2015 5E1309 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 106 KALEIDA HEALTH 16-1533232 Schedule R (Form 990) 2015 Page 3 Part V Transactions With Related Organizations Complete if the organization answered "Yes" on Form 990, Part IV, line 34, 35b, or 36.
Note. Complete line 1 if any entity is listed in Parts II, III, or IV of this schedule. Yes No 1 During the tax year, did the organization engage in any of the following transactions with one or more related organizations listed in Parts II-IV? a Receipt of (i) interest, (ii) annuities, (iii) royalties, or (iv) rent from a controlled entity 1a b Gift, grant, or capital contribution to related organization(s) 1b c Gift, grant, or capital contribution from related organization(s) 1c d Loans or loan guarantees to or for related organization(s) 1d e Loans or loan guarantees by related organization(s) 1e f Dividends from related organization(s) 1f g Sale of assets to related organization(s) 1g h Purchase of assets from related organization(s) 1h i Exchange of assets with related organization(s) 1i j Lease of facilities, equipment, or other assets to related organization(s) 1j k Lease of facilities, equipment, or other assets from related organization(s) 1k l Performance of services or membership or fundraising solicitations for related organization(s) 1l m Performance of services or membership or fundraising solicitations by related organization(s) 1m n Sharing of facilities, equipment, mailing lists, or other assets with related organization(s) 1n o Sharing of paid employees with related organization(s) 1o p Reimbursement paid to related organization(s) for expenses 1p q Reimbursement paid by related organization(s) for expenses 1q r Other transfer of cash or property to related organization(s) 1r s Other transfer of cash or property from related organization(s) 1s 2 If the answer to any of the above is "Yes," see the instructions for information on who must complete this line, including covered relationships and transaction thresholds. (a) (b) (c) (d) Name of related organization Transaction Amount involved Method of determining type (a-s) amount involved
(1) KALEIDA HEALTH FOUNDATION S 14,584,271. ACTUAL COST
(2) KALEIDA HEALTH FOUNDATION P 133,111. ACTUAL COST
(3) SOUTHTOWNS IMAGING, LLC D 108,171. ACTUAL COST
(4) SOUTHTOWNS IMAGING LLC J 266,180. ACTUAL COST
(5)
(6)
JSA Schedule R (Form 990) 2015 5E1309 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 107 KALEIDA HEALTH 16-1533232 Schedule R (Form 990) 2015 Page 4 Part VI Unrelated Organizations Taxable as a Partnership Complete if the organization answered "Yes" on Form 990, Part IV, line 37. Provide the following information for each entity taxed as a partnership through which the organization conducted more than five percent of its activities (measured by total assets or gross revenue) that was not a related organization. See instructions regarding exclusion for certain investment partnerships. (c) (a) (b) (d) (e) (f) (g) (h) (i) (j) (k) Primary activity Legal domicile Predominant Are all partners Share of Share of Code V - UBI General or Name, address, and EIN of entity Disproportionate Percentage (state or foreign income (related, section total income end-of-year allocations? amount in box 20 managing ownership country) unrelated, excluded 501(c)(3) assets of Schedule K-1 partner? from tax under organizations? (Form 1065) sections 512-514) Yes No Yes No Yes No (1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
JSA Schedule R (Form 990) 2015 5E1310 1.000
6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 108 KALEIDA HEALTH 16-1533232
Schedule R (Form 990) 2015 Page 5 Part VII Supplemental Information Complete this part to provide additional information for responses to questions on Schedule R (see instructions).
TRANSACTIONS WITH RELATED ORGANIZATIONS
SCHEDULE R, PART V, TRANSACTION TYPE C THERE IS A VARIANCE BETWEEN THE
AMOUNT REFLECTED ON PART VIII, LINE 1D (AND SCHEDULE B) - GIFTS, GRANTS
AND CONTRIBUTIONS FROM THE FOLLOWING RELATED ORGANIZATIONS AND THE AMOUNT
INCLUDED ON SCHEDULE R, PART V AS A RESULT OF THE VARIANCE IN TIMING OF
THE RECORDING OF THE TRANSFER BETWEEN THE TWO ORGANIZATIONS. KALEIDA
HEALTH FOUNDATION RECORDED GRANTS PAID TO THE FILING ORGANIZATION IN THE
AMOUNT OF $2,230,471 (SEE SCHEDULE R, PART V) VERSUS THE $3,417,726
RECORDED BY THE FILING ORGANIZATION AS GRANTS RECEIVED (SEE PART VIII,
LINE 1D AND SCHEDULE B). THE WOMEN & CHILDREN'S HOSPITAL OF BUFFALO
FOUNDATION RECORDED GRANTS PAID TO THE FILING ORGANIZATION IN THE AMOUNT
OF $1,260,774 (SEE SCHEDULE R, PART V) VERSUS THE $936,328 RECORDED BY
THE FILING ORGANIZATION AS GRANTS RECEIVED (SEE PART VIII, LINE 1D AND
SCHEDULE B).
Schedule R (Form 990) 2015
5E1510 1.000 6261CF 2214 11/17/2016 10:37:20 AM 2667464 PAGE 109